Cumberland Times-News

June 16, 2013

Hospitals release information for safety report

Health care officials document fewer adverse events, but more suicides

From Staff Reports
Cumberland Times-News

— CUMBERLAND — Maryland hospitals had fewer reports of serious adverse events in fiscal 2012 compared to the year before but an increase in suicides, according to the Office of Health Care Quality in Baltimore’s annual Hospital Patient Safety Report.

In fiscal 2012, which ended June 30, hospitals submitted 286 reports of Level 1 adverse events, down from 348 reports in fiscal 2011. Level 1 adverse events are unexpected occurrences related to a patient’s medical treatment and not related to the natural course of the patient’s illness or underlying condition that result in death or a serious disability.

The suicide rate went from five in fiscal 2011 to 16 in fiscal 2012. Nine of the suicides occurred outside the hospital shortly after discharge from emergency departments and inpatient behavioral health units, according to the report.

The document does not identify which hospitals submitted the serious adverse events reports.

Other key findings of the document include:

• Hospitals with more than 100 beds reported an average of 4.8 adverse events each, while those with less than 100 beds reported an average of 0.9 Level 1 events each.

• As with previous years, pressure ulcers and falls continued to make up the majority of the reports received, with 98 and 86 reports, respectively. These two types of events account for nearly two-thirds of all reports in fiscal 12.

• The post-surgical retention of foreign bodies decreased from 17 to 13, with most of the reported events occurring during emergency abdominal procedures in obese patients.

• There were 12 reports of medication errors leading to death or serious disability, including one each of untreated hypoglycemia and anticoagulation events. Five of the errors involved overdoses of sedatives, pain medications and the anesthetic agent propofol.

 The report recommends that:

• Hospitals should consider asking alert and oriented patients to sign an informed declination of services when the patients refuse basic interventions to prevent falls and pressure ulcers.

• Assessments of suicide risk in patients about to be discharged should include an assessment of hazards and the availability of weapons in the home.

• Each suicide attempt should be considered predictive of future behavior. Inpatients with suicidal intent should be on one-to-one or arms-length supervision.

• Hospitals should implement evidence-based assessments, improved safety protocols and maintain a keen awareness of environmental hazards.

• Hospitals should proactively address the contributing factors that are common in medication errors, including communication failures, lack of effective medication reconciliation, dosage calculation failures and complacency.

• Root cause analysis teams should pay more attention to the role of staff supervision (or the lack thereof) in the adverse events. Many adverse events could be averted with timely interventions.

OHCQ works with Maryland hospitals and the Maryland Patient Safety Center to promote its recommendations.

To view the full Fiscal Year 2012 Hospital Patient Safety Report, visit