Dangerous medical errors resulting in death or serious injury tripled in Maryland hospitals between 2019 and 2022.
A state report shows there were 832 adverse events from October 1, 2021 to September 30, 2022, which was also the highest since records began in 2004.
Of last year’s incidents, 769 were classified as the most serious, or Level 1 events, defined as adverse Incidents that result in death or serious disability..
In one case, a patient underwent surgery on one leg and ended up having the other amputated due to a serious medical complication.
In another case, in 2021, three people died after a maintenance worker inadvertently shut off an unlabeled oxygen line.
Another blunder involved a low-birth-weight premature baby receiving the wrong dose of steroids for nearly two weeks.
The graph above shows the number of adverse events reported in Maryland hospitals from 2004 to 2022.
The graph above shows the comparison between 2021 and 2022 of different types of adverse events in Maryland hospitals.
The graph above shows the number of different types of adverse events in Maryland hospitals in fiscal year 2022.
Overall events in 2022 represented a 52 percent increase over 2021, and the highest the state has recorded since it began collecting data in 2004.
The report, which partially attributed the increase in adverse events to reduced staffing and supply shortages during the Covid-19 pandemic, included results from 62 hospitals across the state of Maryland, but did not indicate in which hospitals the events occurred. events.
The Leapfrog Group, a private organization that evaluates hospital safety metrics, ranked Maryland 35th in patient safety and only gives nine hospitals in the state its highest safety rating, Level A.
Of the adverse events, pressure injuries, falls, treatment delays, and surgical events accounted for 80 percent. In-hospital physical and sexual assaults increased by 75 percent in 2022.
Based on the findings, the report’s authors emphasized that hospitals must prioritize safety and optimize processes to avoid system failures that could lead to serious errors.
As part of the report, the authors highlighted several adverse events they observed and provided “lessons learned” to guide hospital staff in preventing similar outcomes in the future.
Pressure injuries, or pressure ulcers and pressure sores, saw the largest increase, approximately doubling from 184 in 2021 to 375 in 2022.
These are injuries to the skin and soft tissues that result from constant or prolonged pressure on the skin, such as when a patient lies in a hospital bed for a long period without moving.
Falls were the second most common adverse event and saw a slight increase from 136 to 148.
In one fall, a patient fell in her room and hit her head, suffering a subdural hematoma or brain hemorrhage. After developing symptoms such as nausea and headache, tests revealed the patient’s condition, forcing her to be transferred to another facility and undergo brain surgery.
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For the future, the report’s authors recommend that patients be assessed for fall risk, informed about their fall risk, that hospital staff perform multiple tests for head injuries, and that beds and alarms of falls are operational.
Surgical adverse events include all those involving foreign objects in the patients’ body, deaths in healthy patients undergoing low-risk procedures, and unexpected deaths during or immediately after surgery.
These incidents doubled from 31 events in 2021 to 64 in 2022.
In one of these events highlighted in the report, a post-surgical patient who had surgery on one of his legs developed a condition in the other leg called compartment syndrome, when pressure in the muscles increases to dangerous levels, threatening oxygen and blood flow. .
According to the report, the resident physician did not order typical evaluation procedures, so nurses did not monitor the patient as frequently as they should for complications after surgery.
Overnight, the patient’s health worsened and his surgeon was not immediately informed. By morning, the patient’s condition had worsened beyond the time of treatment and he was sent back to the operating room for a below-knee amputation.
If the correct assessments had been performed or more observations of the patient had been made, the report states, compartment syndrome could have been detected earlier and the outcome could have been different.
In more than 50 events, delays in treatment led to adverse outcomes. One case the report’s author focused on was the death of a patient as a result of inadequate monitoring and unclear communication, which caused nurses to fail to detect when the patient’s heart stopped.
“Lessons learned” included evaluating alarms and functionality of monitoring machines, ensuring staff are aware of all functions of monitoring equipment, and developing and optimizing a process for interdepartmental communication.
Other adverse events included in the report included a premature baby receiving four times the maximum daily dose of a steroid for 13 days. Several hospital staff members reviewed the dosage and instructions and were unable to detect the error.
Another saw a woman with a history of bipolar disorder leave the emergency department undetected while waiting to be admitted to the behavioral health unit. She then committed suicide by jumping from a bridge into the river.
Hospitals must report Level 1 adverse events to the state and must investigate what caused the harm and submit a plan to the state that outlines their plans to fix any problems.
While the state approves the plans, it does not make public the adverse events or resulting solutions.
The report owes part of the increase to the Covid-19 pandemic. Since the pandemic, there has been a significant increase in reports of Level 1 adverse events compared to previous years.
And Covid-19 had a “significant adverse impact on the healthcare system.”
He added: “Healthcare organizations have faced countless challenges, including changes to workflows, supply constraints and a shrinking workforce.”
Additionally, the authors say the report highlights that while people can make mistakes, “the problem is not bad people in healthcare, but good people working in poorly designed systems” that increase the risk of making mistakes. .
The report partly blames the increase on healthcare organizations with punitive policies that could make staff hesitant to report errors or document problems. This inaction can contribute to “a culture of complacency and continuation of patient safety events.”
To avoid this, the authors say health centers must create a culture of shared responsibility and coordinated responses to fix problems as they arise.