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Importance: Patient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade.Objective: To determine the change in the rate of adverse events in hospitalized patients.Design, Setting, and Participants: This serial cross-sectional study used data from the Medicare Patient Safety Monitoring System from 2010 to 2019 to assess in-hospital adverse events in patients. The study included 244 542 adult patients hospitalized in 3156 US acute care hospitals across 4 condition groups from 2010 through 2019: acute myocardial infarction (17%), heart failure (17%), pneumonia (21%), and major surgical procedures (22%); and patients hospitalized from 2012 through 2019 for all other conditions (22%).Exposures: Adults aged 18 years or older hospitalized during each included calendar year.Main Outcomes and Measures: Information on adverse events (abstracted from medical records) included 21 measures across 4 adverse event domains: adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events (hospital-acquired pressure ulcers and falls). The outcomes were the total change over time for the observed and risk-adjusted adverse event rates in the subpopulations.Results: The study sample included 190 286 hospital discharges combined in the 4 condition-based groups of acute myocardial infarction, heart failure, pneumonia, and major surgical procedures (mean age, 68.0 [SD, 15.9] years; 52.6% were female) and 54 256 hospital discharges for the group including all other conditions (mean age, 57.7 [SD, 20.7] years; 59.8% were female) from 3156 acute care hospitals across the US. From 2010 to 2019, the total change was from 218 to 139 adverse events per 1000 discharges for acute myocardial infarction, from 168 to 116 adverse events per 1000 discharges for heart failure, from 195 to 119 adverse events per 1000 discharges for pneumonia, and from 204 to 130 adverse events per 1000 discharges for major surgical procedures. From 2012 to 2019, the rate of adverse events for all other conditions remained unchanged at 70 adverse events per 1000 discharges. After adjustment for patient and hospital characteristics, the annual change represented by relative risk in all adverse events per 1000 discharges was 0.94 (95% CI, 0.93-0.94) for acute myocardial infarction, 0.95 (95% CI, 0.94-0.96) for heart failure, 0.94 (95% CI, 0.93-0.95) for pneumonia, 0.93 (95% CI, 0.92-0.94) for major surgical procedures, and 0.97 (95% CI, 0.96-0.99) for all other conditions. The risk-adjusted adverse event rates declined significantly in all patient groups for adverse drug events, hospital-acquired infections, and general adverse events. For patients in the major surgical procedures group, the risk-adjusted rates of events after a procedure declined significantly.Conclusions and Relevance: In the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety. [ABSTRACT FROM AUTHOR]

Fifth, consistent with the OIG report, our study[1] demonstrated that patient safety remains a serious concern and improvements are necessary. Comment & Response B In Reply b In response to the OIG's letter about our article,[1] which concluded that there was a significant decrease in the rates of adjusted adverse events for hospital patients between 2010 and 2019, we agree that too many adverse events occurred, and efforts should be focused on lowering their frequency. First, in their 2022 report,[2] the OIG noted that its "sample size was insufficient to effectively compare the results of this report to the harm rates identified in the 2010 report", with each of the 2 OIG reports including 700 to 800 medical records. [Extracted from the article]

They stated that "If the goal is zero harms, research should test whether adverse event outcomes are significantly closer to zero rather than how the trends in adverse event outcomes compare with 2010 rates, or at least rates meaningful to patients such as a 50% rate reduction - a median that none of the adverse event rates crossed."[1] Although no group of patients had an overall adverse event rate reduced by 50% in our study,[2] the observed data showed reductions ranging from 31% to 39% for the 4 condition-based patient groups (from 2010 to 2019); in the risk-adjusted data, the relative risk of experiencing 1 or more adverse events per hospitalization was reduced by 35% to 45% at the patient level (eFigure 2A in the article's Supplement).[2] For the all other conditions group, no adverse event rate reduction was seen in the observed data (2012 to 2019), but the relative risk was reduced by 19% after risk adjustment for 1 or more adverse events per hospitalization. Comment & Response B To the Editor b I have some concerns about the Editorial[1] that was written about our recent article.[2] First, the Editorial stated that "...patients may be less convinced that risk-adjusted annual declines of 6% in the rates of acute myocardial infarction or pneumonia, for instance, imply that hospitals are adequately safer today."[1] However, our study[2] did not address findings related to the rates of acute myocardial infarction or report a decrease of 6% in pneumonia. We addressed adverse events experienced by 5 groups of patients, and 2 of the 5 groups were patients with acute myocardial infarction and pneumonia. [Extracted from the article]

The article presents a study on the trends in the Medicare Patient Safety Monitoring System (MPSMS) ventilator-associated pneumonia (VAP) rates in the U.S. from 2005 to 2013. Also cited are the decreasing incidence of VAP from 2006 to 2012 as reported by the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN), and the participants in the study, particularly the older patients with principal diagnosis of heart failure and similar ailments.

Objective: To describe incorrect surgical procedures reported from mid-2006 to 2009 from Veterans Health Administration medical centers and build on previously reported events from 2001 to mid-2006. Design: Retrospective database review. Setting: Veterans Health Administration medical centers. Interventions: The Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety. Main Outcome Measures: The categories were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm. Results: Our review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P=.02). Reported close calls increased from 1.97 to 3.24 per month (P⩽.001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%). Conclusions: The rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed. [ABSTRACT FROM AUTHOR]

Background Incident-reporting systems (IRS) collect snapshots of hazards, mistakes and system failures occurring in healthcare. These data repositories are a cornerstone of patient safety improvement. Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation. Discussion Patient safety experts from eight countries convened in 2008 to establish a global community to advance the science of learning from mistakes. This convenience sample of experts all had experience managing large incident-reporting systems. This article offers guidance through a presentation of expert discussions about methods to identify, analyse and prioritise incidents, mitigate hazards and evaluate risk reduction. [ABSTRACT FROM PUBLISHER]

Objective: To describe incorrect surgical procedures reported from Veterans Health Administration (VHA) Medical Centers from 2001 to mid-2006 and provide proposed solutions for preventing such events. Design: Descriptive study. Setting: Veterans Health Administration Medical Centers. Participants: Veterans of the US Armed Forces. Interventions: The VHA instituted an initial directive, "Ensuring Correct Surgery and Invasive Procedures," in January 2003. The directive was updated in 2004 to include non-operating room (OR) invasive procedures and incorporated requirements of The Joint Commission Universal Protocol for preventing wrong-site operations. Main Outcome Measures: The categories included 5 incorrect event types (wrong patient, side, site, procedure, or implant), major or minor surgical procedures, location in or out of the OR, therapeutic or diagnostic events, adverse event or close call, inpatient or ambulatory events, specialty department, body segment, and severity and probability of harm. Results: We reviewed 342 reported events (212 adverse events and 130 close calls). Of these, 108 adverse events (50.9%) occurred in an OR, and 104 (49.1%) occurred elsewhere. When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2%] each), whereas orthopedics was second to ophthalmology for number of reported adverse events occurring in the OR. Pulmonary medicine cases (such as wrong-side thoracentesis) and wrong-site cases (such as wrong spinal level) were associated with the most harm. The most common root cause of events was communication (21.0%). Conclusions: Incorrect ophthalmic and orthopedic surgical procedures appear to be overrepresented among adverse events occurring in ORs. Outside the OR, adverse events by invasive radiology were most frequently reported. Incorrect surgical procedures are not only an OR challenge but also a challenge for events occurring outside of the OR. We support earlier communication based on crew resource management to prevent surgical adverse events. [ABSTRACT FROM AUTHOR]

Background: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement.Objective: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO.Design: Six Sigma Project with pre-post design.Participants: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals.Measurements: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire.Results: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products.Conclusions: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use. [ABSTRACT FROM AUTHOR]

Population densities are almost without exception calculated using gross area data. This paper calculates densities using a measure of residential area and reports on the statistically preferred areal unit. [ABSTRACT FROM PUBLISHER]