223834 Adverse events in hospitals: National incidence among medicare beneficiaries

Wednesday, November 10, 2010 : 12:50 PM - 1:10 PM

Amy Ashcraft, MPA , Office of Inspector General, U.S. Department of Health and Human Services, Dallas, TX
The U.S. Department of Health and Human Services, Office of the Inspector General (OIG) is completing a series of reports regarding adverse events in hospitals. Congress mandated in 2006 that the OIG study the incidence of adverse events among hospitalized Medicare beneficiaries and associated Medicare costs. OIG released four reports between 2008 2009 and will release two additional reports prior to the APHA conference in November 2010. Topics include incident reporting systems, nonpayment policies, and public disclosure of event information. We propose presenting the centerpiece study of the series, which will be publicly reported in March 2010. This report establishes a national incidence rate for adverse events among hospitalized Medicare beneficiaries based on a physician medical record review. OIG selected a random sample of Medicare beneficiaries hospitalized in October 2008. Nurses and medical coders reviewed the medical records and claims for all sample beneficiaries then a panel of physician experts conducted a full medical record review for cases suspected to contain an adverse event. The physician panel was comprised of five experts in patient safety, including an infectious disease specialist, cardiologist, surgeon, internist, and cardiologist. In addition to providing an incidence rate for adverse events, the study details the nature of the events, an assessment of the extent to which they were preventable, and the resulting costs to Medicare. The occurrences found by the study include temporary harm events (such as delirium as a result of medication), events that prolonged hospitalization (such as catheter-associated urinary tract infections) and serious events resulting in permanent disability or death. The report represents the first effort to provide a national incidence rate for adverse events since the release of the IOM's To Err is Human Report, as well as the first effort to measure the effect of Medicare's Hospital-Acquired Condition nonpayment policy.

Learning Areas:
Conduct evaluation related to programs, research, and other areas of practice
Public health administration or related administration
Public health or related education
Public health or related laws, regulations, standards, or guidelines
Public health or related organizational policy, standards, or other guidelines
Public health or related public policy

Learning Objectives:
1) Compare the incidence rate of preventable and non-preventable adverse events among Medicare beneficiaries. 2) Assess the impact of preventable adverse events on Medicare beneficiaries. 3) Explain common contributory factors associated with preventable adverse events.

Keywords: Medicare/Medicaid, Health Risks

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am qualified to present because I have led over 15 national evaluations for the U.S. Department of Health and Human, including our series of work on adverse events in hospitals.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.