Trends in Adverse Event Rates in Hospitalized Patients, 2010-2019.

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.

Time Trends in Patient Characteristics and In-Hospital Adverse Events for Primary Total Knee Arthroplasty in the United States: 2010-2017.

BACKGROUND: Perioperative care for total knee arthroplasty (TKA) has improved over time. We present an analysis of inpatient safety after TKA. METHODS: 14,057 primary TKAs captured by the Medicare Patient Safety Monitoring System between 2010 and 2017 were retrospectively reviewed. We calculated changes in demographics, comorbidities, and adverse events (AEs) over time. Risk factors for AEs were also assessed. RESULTS: Between 2010 and 2017, there was an increased prevalence of obesity (35.1% to 57.6%), tobacco smoking (12.5% to 17.8%), and renal disease (5.2% to 8.9%). There were reductions in coronary artery disease (17.3% to 13.4%) and chronic warfarin use (6.7% to 3.1%). Inpatient AEs decreased from 4.9% to 2.5%, (P < .01), primarily driven by reductions in anticoagulant-associated AEs, including major bleeding and hematomas (from 2.8% to 1.0%, P < .001), catheter-associated urinary tract infections (1.1% to 0.2%, P < .001), pressure ulcers (0.8% to 0.2%, P < .001), and venous thromboembolism (0.3% to 0.1%, P = .04). The adjusted annual decline in the risk of developing any in-hospital AE was 14% (95% confidence interval [CI] 10%-17%). Factors associated with developing an AE were advanced age (odds ratio [OR] = 1.01, 95% CI 1.00-1.01), male sex (OR = 1.21, 95% CI 1.02-1.44), coronary artery disease (OR = 1.35, 95% CI 1.07-1.70), heart failure (OR = 1.70, 95% CI 1.20-2.41), and renal disease (OR = 1.71, 95% CI 1.23-2.37). CONCLUSIONS: Despite increasing prevalence of obesity, tobacco smoking, and renal disease, inpatient AEs after primary TKA have decreased over the past several years. This improvement is despite the increasing complexity of the inpatient TKA population over time.

Predictors of warfarin-associated adverse events in hospitalized patients: Opportunities to prevent patient harm.

BACKGROUND: The optimum international normalized ratio (INR) monitoring frequency for hospitalized patients receiving warfarin is unknown. OBJECTIVE: Assess relationship between daily versus less frequent INR monitoring and overanticoagulation and warfarin-related adverse events. DESIGN: Retrospective cohort study using Medicare Patient Safety Monitoring System data. SETTING: Randomly selected acute care hospitals across the United States. PATIENTS: Patients hospitalized from 2009 to 2013 for pneumonia, acute cardiac disease, or surgery who received warfarin. INTERVENTIONS: None. MEASUREMENTS: (1) Association between frequency of INR monitoring and an INR ≥6.0 or warfarin-related adverse event. (2) Association between the rate of change of the INR and a subsequent INR ≥5.0 and ≥6.0. RESULTS: Among 8529 patients who received warfarin for ≥3 days, for 1549 (18.2%) the INR was not measured on 2 or more days. These patients had higher propensity-adjusted odds ratios (ORs) of having a warfarin-associated adverse event (OR: 1.48, 95% confidence interval [CI]: 1.02-2.17) for cardiac patients and surgical patients (OR: 1.73, 95% CI: 1.20-2.48), with no significant association for pneumonia patients. Cardiac and pneumonia patients with 1 day or more without an INR measurement had higher propensity-adjusted ORs of having an INR ≥6.0 (OR: 1.61, 95% CI: 1.07-2.41 and OR: 1.92, 95% CI: 1.36-2.71, respectively). A 1-day increase in the INR of ≥0.9 occurred in 621 patients (12.5%) and predicted a subsequent INR of ≥6.0 (positive likelihood ratio of 4.2). CONCLUSION: Daily INR measurement and recognition of a rapidly rising INR might decrease the frequency of warfarin-associated adverse events in hospitalized patients.

Racial and ethnic disparities in healthcare-associated infections in the United States, 2009-2011.

BACKGROUND: Little is known about racial and ethnic disparities in the occurrence of healthcare-associated infections (HAIs) in hospitalized patients. OBJECTIVE: To determine whether racial/ethnic disparities exist in the rate of occurrence of HAIs captured in the Medicare Patient Safety Monitoring System (MPSMS). METHODS: Chart-abstracted MPSMS data from randomly selected all-payer hospital discharges of adult patients (18 years old or above) between January 1, 2009, and December 31, 2011, for 3 common medical conditions: acute cardiovascular disease (composed of acute myocardial infarction and heart failure), pneumonia, and major surgery for 6 HAI measures (hospital-acquired antibiotic-associated Clostridium difficile, central line-associated bloodstream infections, postoperative pneumonia, catheter-associated urinary tract infections, hospital-acquired methicillin-resistant Staphylococcus aureus, and ventilator-associated pneumonia). RESULTS: The study sample included 79,019 patients who had valid racial/ethnic information divided into 6 racial/ethnic groups-white non-Hispanic (n = 62,533), black non-Hispanic (n = 9,693), Hispanic (n = 4,681), Asian (n = 1,225), Native Hawaiian/Pacific Islander (n = 94), and other (n = 793)-who were at risk for at least 1 HAI. The occurrence rate for HAIs was 1.1% for non-Hispanic white patients, 1.3% for non-Hispanic black patients, 1.5% for Hispanic patients, 1.8% for Asian patients, 1.7% for Native Hawaiian/Pacific Islander patients, and 0.70% for other patients. Compared with white patients, the age/gender/comorbidity-adjusted odds ratios of occurrence of HAIs were 1.1 (95% confidence interval [CI], 0.99-1.23), 1.3 (95% CI, 1.15-1.53), 1.4 (95% CI, 1.07-1.75), and 0.7 (95% CI, 0.40-1.12) for black, Hispanic, Asian, and a combined group of Native Hawaiian/Pacific Islander and other patients, respectively. CONCLUSIONS: Among patients hospitalized with acute cardiovascular disease, pneumonia, and major surgery, Asian and Hispanic patients had significantly higher rates of HAIs than white non-Hispanic patients.

The association between age, sex, and hospital-acquired infection rates: results from the 2009-2011 National Medicare Patient Safety Monitoring System.

OBJECTIVE: To define the relationships between age, sex and hospital-acquired infection (HAI) rates in a national cohort of hospitalized patients. METHODS: Analysis of chart-abstracted Medicare Patient Safety Monitoring System data from randomly selected medical records of patients hospitalized between January 1, 2009, and December 31, 2011, for acute cardiovascular disease, pneumonia, or major surgery associated with 1 of 6 HAIs. Patients were stratified into 6 groups. We then analyzed the association of age, sex, and 2 outcomes; the rate of occurrence of HAI for patients who were at risk and the rate of patients having at least 1 HAI. RESULTS: Among 85,461 patients, all groups except younger female surgical patients had higher catheter-associated urinary tract infection (CAUTI) rates than male patients. After adjustment for comorbidities, there was no overall evidence of higher HAI rates among elderly patients. In patients with acute cardiovascular disease, women had higher rates of HAIs. Among patients with pneumonia, there was no significant difference in the rate of HAIs among most age and sex groups. Among surgical patients, all age and sex groups had a significantly higher adjusted rate of developing at least 1 HAI except females 65 years of age or older. Similar results were seen for the outcome of the occurrence rate of HAIs. CONCLUSIONS: There was not an overall increased risk of HAIs among older patients hospitalized for acute cardiovascular disease, pneumonia, and major surgery after adjustment for comorbidities. The relationship between sex and the rate of HAIs varied depending upon the underlying acute reason for hospitalization.