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October 21, 2016

State: Hospital error deaths, injuries down 3%

By Kym Soper | Journal Inquirer

Deaths and injuries from hospital errors were down by 3 percent last year, with most incidents attributed to bedsores, falls, unintended perforation during diagnostic procedures, and surgical mistakes.

Those four categories accounted for 85 percent of all adverse events reported to the state Public Health Department in 2015, according to the agency’s annual report released this month.

As of Sept. 30, 2016, there were 456 adverse events in 2015, with roughly 50 percent, or 230, attributed to pressure ulcers, otherwise known as open wound bedsores, primarily on patients 65 and older being treated in an adult, medical ward. That’s down from 245 bedsores reported in 2014.

Patient falls, meanwhile, are trending upward and were the second-most common event to result in death or serious injury, with 90 adverse event reports, or 20 percent of the total for 2015. The previous year there were 78 falls reported by medical facilities.

Tissue punctures during invasive tests such as endoscopy accounted for 11 percent, or 49 reports, while 19 reports, or 4 percent, involved foreign objects left in patients after surgery, or operations done on the wrong person or body part.

Locally, Eastern Connecticut Health Network facilities had a number of reportable incidents, but they were relatively low when compared with other similar-sized facilities and the number of days patients were in their care.

Manchester Memorial Hospital reported a total of six adverse incidents in 2015, at a rate of 15.3 per 100,00 patient days in 2015. The incidents include one surgery performed on the wrong body part; one maternal death or serious injury associated with labor and delivery of a low-risk pregnancy; two patient deaths or serious injuries resulting from a fall in a health care setting; and two patients developing bedsores after being admitted.

Rockville General Hospital in Vernon, meanwhile, had only two incidents in 2015, both associated with a patient falling, for a rate of 20.7 events per 100,000 patient days.

Evergreen Endoscopy, which is affiliated with ECHN and located in South Windsor, had one perforation during open, laparoscopic and/or endoscopic procedures resulting in death or serious injury, out of the 3,717 performed at that facility 2015.

Windham Community Memorial Hospital, meanwhile, reported only one incident in 2015 of a patient falling, for a rate of 8.3 per 100,000 patient days.

And Johnson Memorial Hospital in Stafford reported no adverse incidents for 2015. The hospital, which was taken over last year by St. Francis Hospital and Medical Center, typically reports two or three each year. Having none in 2015 for that size facility shouldn’t be seen as an anomaly, public health officials say.

Because of changes in how bedsores are categorized, the numbers for this year can’t be compared directly with previous years, public health officials say.

That, and other improvements in reporting or initiating safety protocols, may be why the numbers on the whole have leveled off after a staggering climb to 456 in 2015, up from 241 in 2012, health care officials say.

Overall, the total number of adverse events in 2015 is down from 472 in 2014 and 534 in 2013.

Of the 456 total incidents reported, 88 percent, or 401 came from acute-care or children’s hospitals. The rest were from chronic disease hospitals, mental health facilities, and outpatient surgical units not affiliated with a hospital.

As expected, the state’s largest hospitals had the highest numbers due to their increased volume of patients. Yale New Haven reported 76; St. Francis in Hartford reported 50; and St. Vincent’s Medical Center in Bridgeport reported 43.

Bristol Hospital was the standout, however, when the numbers are adjusted for its patient population with a rate of 53.2 adverse events in 2015 per 100,000 patient days.

ECHN facilities were recently bought by the California-based for-profit, Prospect Medical Holdings Inc., in a $105 million deal.

Also this month Prospect purchased Waterbury Hospital, which reported 12 adverse events for 2015, a rate of 22.7 out of 100,000 patient days.

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