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Safety Issues: Hot Topics
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Here are some short discussions and lists of resources concerning a few specially hot topics in health care safety. Health care consumers, patients and families, see also the page Important Patient Safety Issues: What You Can Can Do.


Diagnostic Errors

Diagnostic errors have been a neglected topic in patient safety until recently but are now receiving increasing attention. These errors are defined as “a diagnosis that was either “wrong, missed, or unintentionally delayed.” A systematic review of the literature suggests that up to 8.4 percent of hospitalized patients are subject to a major diagnostic error. Outside the surgical specialties, faulty diagnosis is the most common type of medical error. In the Harvard Medical Practice Study, diagnostic error accounted for 17 percent of preventable errors in hospitalized patients, and a systematic review of autopsy studies covering four decades found that approximately 9 percent of patients experienced a major diagnostic error that went undetected while the patient was alive. Taken together, these studies imply that thousands of hospitalized patients die every year due to diagnostic errors.

Diagnostic errors can be broken down into three subcategories: no-fault, system-related, and cognitive. No-fault errors are attributable to masked or unusual presentation of a disease, and to patient-related factors such as lack of cooperation and deception. System-related errors include technical failure, equipment problems and organizational flaws. Cognitive errors frequently occur when clinicians rely on heuristics to come up with a provisional diagnosis, especially when faced with a patient with common symptoms s. This process usually works but has its exceptions. We should remember that all people employ this strategy (whether they know it or not), and that we are all capable of making mistakes, even the most experienced of doctors. Personal causal factors are varied and common.

Missed or delayed diagnoses (particularly cancer diagnoses) are a prominent reason for malpractice claims, and much of the research into systems causes of diagnostic error arises from studies of closed malpractice claims in primary care, pediatrics, emergency medicine, and surgery. Poor teamwork and communication between clinicians have been identified as predisposing factors for diagnostic error in emergency medicine and surgery. Lack of reliable systems for common outpatient clinical situations, such as triaging acutely ill patients by telephone and following up on test results, also increases the likelihood of diagnostic error.


AHRQ Patient Safety Network – Diagnostic Errors. AHRQ Patient Safety Network. Web. Accessed 27 July 2011. Available at:

Diagnostic Error. International Medical Litigation Consultants (Medlit). Electronic Handbook of Legal Medicine. Web. Accessed 27 July 2011. Available at:

Groopman, Jerome. ‘How Doctors Think’ : NPR. 14 Mar. 2007. NPR : National Public Radio. Houghton Miflin Company. Web. 27 July 2011. Available at: [Audio and book excerpt].

McNutt, Robert, Richard Abrams, and Scott Hasler. Diagnosing Diagnostic Mistakes. AHRQ WebM&M: Morbidity & Mortality Rounds on the Web. Agency for Healthcare Research and Quality, May 2005. Available at:

Newman-Toker DE and Pronovost PJ. Diagnostic Errors–The Next Frontier for Patient Safety. JAMA. 2009;301(10):1060-1062. doi: 10.1001/jama.2009.249. Abstract available at: Accessed 27 July 2011.

Trowbridge, Robert, and Doug Salvador. Addressing Diagnostic Errors: An Institutional Approach. Focus on Patient Safety – A Newsletter from the National Patient Safety Foundation Volume 13, Issue 3 (2010).

Falls (inpatient)

Falls among hospital inpatients are common, generally ranging from 2.3 to 7 falls per 1,000 patient-days. Approximately 30 percent of inpatient falls result in injury, with 4 percent to 6 percent resulting in serious injury. These serious fall-related injuries can include fractures, subdural hematomas, excessive bleeding, and even death. Injuries due to falls also increase health care costs. 4 to 7.5 percent of hospital acquired falls result in subdural hematoma, fractures, crushing injury and dislocations. Using conservative estimates, there are more than 500,000 falls each year in U.S. hospitals, resulting in 150,000 injuries.

The annual incidence of falls among the elderly is estimated to be approximately 220 per 1000 or seven million annually. The CDC reported that more than a third of adults over 65 fall each year and that the total direct costs of all fall injuries in the elderly in 2000 exceeded $19 billion. Furthermore, the costs of injurious falls are expected to reach $32.4 billion by 2020.

Four factors have been found to be effective predictors of fall risk: impaired memory, muscle weakness, age (>60 years), and ambulatory assist device. Falls can be classified as accidental (~14 percent of falls), unanticipated physiologic (~8 percent of hospital falls) or anticipated physiologic (~78 percent of hospital falls). Accidental falls are primarily preventable related to environmental interventions like equipment checks and nonslip footwear. Because unanticipated falls by nature cannot be prevented, the goal is to create an environment that would reduce injury, should a fall occur. Anticipated physiologic fall interventions should be both protective and preventive: making the environment safe; increasing observation; establishing toilet routines; as well as implementing medication, gait, and mental assessments.

Medications also play a role in that they affect gait, mobility, confusion, and altered waste elimination schedules (as many patients fall on their way to or from the bathroom). Although a few categories of drugs can statistically be proven to add additional falls risk, most do not. Whether or not the patient exhibits side effects from a medication better predicts increased fall risk. Studies have also shown that elderly patients taking four or more prescription medications are at three time’s greater risk for falls. A meta-analysis of studies of elderly individuals found that use of sedatives, hypnotics, antidepressants, or benzodiazepines was significantly associated with increased risk for falls. Other classes of medications were not significantly associated with falls.

Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of Forensic Science 1996;41(5):733–46.

Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults: a 1–year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.

Hendrich, A., Nyhuuis, A., Kippenbrock, T., & Soga, M.E. (1995). Hospital falls: Development of a predictive model for clinical practice. Applied Nursing Research, 8, 129-139.

Lane AJ. Evaluation of the fall prevention program in an acute care setting. Orthopaedic Nursing, (1999) 18, 37-43.

Monane M, Avorn J. Medications and falls. Causation, correlation, and prevention. Clin Geriatr Med. 1996 Nov;12(4):847-58.

Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, Tinetti ME. Health care utilization and costs in a Medicare population by fall status. Medical Care 1998;36(8): 1174–88.

Rubinstein, LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing (September 2006) 35(suppl 2): ii37-ii41 doi:10.1093/ageing/afl084.

Woolcott JC, et al. Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Intern Med. 2009;169(21):1952-1960. Available at: Accessed Oct. 17, 2011.

Hospital-Acquired Infections

A hospital-acquired infection (HAI), also referred to as a nosocomial infection, is a disease or infection acquired during the course of treatment at a medical facility which was not previously present in the patient. The infection often presents within 48 hours of admission, but infections which present after discharge are also considered HAIs if the pathogen was acquired during treatment.

The World Health Organization estimates that around 8.7 percent of hospital patients worldwide have an HAI at any given time. In the United States, 1 out of 20 hospitalized patients contract HAIs and 100,000 die each year, but as of 2010 only 27 states have laws requiring hospitals to report their rates of infection. For patients, the cost of an HAI is high; the length of the hospital stay increases by 7-9 days, and they pay $40,000 more on average. For the healthcare system as a whole, HAIs add between $4.5 and $5.7 billion each year.

The three most common types of HAIs are:
  • Catheter-related bloodstream infections: Catheter-related bloodstream infections, or CRBSIs, are among the most common infections in ICU patients. They occur when bacteria and other germs travel down a “central line” and enter the bloodstream. Symptoms include fever and chills, and frequently, the skin around the catheter becomes sore and red. It is estimated that 70 percent of hospital-acquired bloodstream infections occur in patients with venous catheters. CRBSIs have been estimated to occur in 3 to 7 percent of catheters used, and affect more than 200,000 patients in the United States annually. Previous studies have shown these infections to be associated with attributable mortality, length of hospital stay, and cost. Assuming a nosocomial infection rate of 5 percent, of which 10 percent are bloodstream infections, and an attributable mortality rate of 15 percent, bloodstream infections would represent the eighth leading cause of death in the United States.
  • Hospital-acquired pneumonia: Hospital-acquired pneumonia (HAP) is an infection of the lungs that occurs 48 hours or longer after admission to a hospital. This pneumonia tends to be more serious because patients in the hospital are often sicker and unable to fight off germs. Hospital-acquired pneumonia occurs more often in patients who are using a respirator machine to help them breathe. VAP, or ventilator-associated pneumonia is a subtype of HAP and it develops 48 hours or longer after ventilation is given by means of an endotracheal tube or tracheotomy. There are several risk factors and prevalent conditions for developing this type of pneumonia. They include alcoholism, aspiration, chest surgery, immunosuppression, old age, recent illness, and chronic lung disease. Common symptoms include coughing, fever, chills, fatigue, malaise, headache, loss of appetite, nausea and vomiting, shortness of breath, and sharp or stabbing chest pain that gets worse with deep breathing or coughing. Rarer symptoms include excessive sweating and joint or muscle stiffness. HAP is the second most common nosocomial infection. HAP increases a patient’s hospital stay by approximately 7 to 9 days and can increase hospital costs by an average of $40,000 per patient.
  • Surgical site infections (SSI): A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material. Symptoms include fever, drainage of cloudy fluid from surgical wound, and redness and pain around surgical area. Most SSIs can be treated with antibiotics. The antibiotic given depends on the bacteria causing the infection. Sometimes patients with SSIs also need another surgery to treat the infection. Each year, approximately 500,000 surgical patients develop SSIs. It has also been estimated that infections develop in about 1 to 3 out of every 100 patients who have surgery. With current trends toward shortened hospital stays and increased outpatient surgery, statisticians estimate that from 47 percent to 84 percent of SSIs may occur after discharge and thus go undetected by hospital infection surveillance programs. The hospital costs associated with these infections are in excess of $7 billion (in 2002 dollars). When the substantial indirect costs to patients, their families, their communities, and their employers are factored in, the impact is even more dramatic.

Amanullah S. Ventilator-Associated Pneumonia. Ed. Zab Mosenifar, MD. 31 May 2011. Available at: Accessed: 26 July 2011.

Centers for Disease Control and Prevention. 2014. National and State Healthcare Associated Infections Progress Report. Available at:

Centers for Disease Control and Prevention. 2011. Surgical Site Infection (SSI). July 12. Available at: Accessed 27 July 2011.

CDC-FAQs about SSI’s. Centers for Disease Control and Prevention. 24 Nov. 2010. CDC, NCEZID, DHQP. Accessed 27 July 2011.

FAQs About Surgical Site Infections. SHEA (Society of Healthcare Epidemiology of America). SHEA, IDSA, AHA, APIC, CDC, The Joint Commission. Available at: Accessed 26 July 2011.

Nash D. High rate of surgical site infections (SSIs) in our nation’s hospitals. Accessed 27 July 2011.

Perl TM and Cosgrove S. Catheter Associated BSI. Johns Hopkins Medicine. Baltimore, Maryland. Centers for Disease Control and Prevention. Available at: Accessed 26 July 2011 .

Vorvick LJ and Hadjiliadis D. Hospital-acquired pneumonia: Medline Plus Medical Encyclopedia. National Library of Medicine – National Institutes of Health. 19 Feb. 2011. Available at: Accessed 27 July 2011.

Wenzel RP and Edmond MB. The impact of hospital-acquired bloodstream infections. Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia. Available at: Accessed 26 July 2011 .



Hospitalizations are costly, accounting for approximately 31 percent of total health care expenditures, according to a 2008 statistic. According to the same source, 18 percent of Medicare patients discharged from the hospital have a readmission within 30 days of discharge, accounting for $15 billion in spending. For Medicare patients recovering from surgery, the readmission rate is an astonishing 50 percent. Many factors may contribute to these avoidable hospital readmissions such as poor quality care or from poor transitions between different providers and care settings. Readmissions may also occur if patients are discharged from hospitals prematurely, or if they are discharged to inappropriate settings, or if they do not receive adequate information or resources to aid in recovery.

According to a New England Journal of Medicine study analyzing close to “12 million fee-for-service Medicare beneficiaries,” nearly 20 percent of those discharged were readmitted within 30 days; 34 percent were rehospitalized within 90 days, and 56 percent, within one year.


Agency for Healthcare Research and Quality, “Educating Patients Before They Leave the Hospital Reduces Readmissions, Emergency Department Visits and Saves Money,” Feb. 2, 2009,

Clancy CM. Reengineering Hospital Discharge: A Protocol to Improve Patient Safety, Reduce Costs, and Boost Patient Satisfaction. American Journal of Medical Quality. June 2009. Extract available at: Accessed 27 July 2011.

Jencks SF, Williams MV, & Coleman EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med. 360:1418-1428. April 2, 2009. Full artcile available at Accessed 27 July 2011.

Medication Errors

Medication errors are unfortunately very common. The statistics for medication errors vary widely depending on the study and the methodology but it is fair to say that these figures are far too high given that most of these adverse drug events (or ADEs) could be prevented entirely.
  • Serious medication errors occur in the cases of 5 to 10 percent of patients admitted to hospitals.
  •  According to a 2001 figure from the Agency for Health Research and Quality (AHRQ), adverse drug events cause more than 770,000 injuries and deaths each year and cost up to $5.6 million per hospital. 
  • A 2006 article from the Washington Post reports that at least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications. 
  • Approximately 1.3 million people are injured annually in the United States following so-called “medication errors.” (FDA) 
  • According to the Institute of Medicine’s July 2006 report Preventing Medication Errors, medication errors harm an estimated 1.5 million Americans each year, resulting in upward of $3.5 billion in extra medical costs. 
  • Patients who suffered unintended drug events remained in the hospital an average of 8 to 12 days longer than patients who did not experience such mistakes. These added days mean their hospital stays cost $16,000 to $24,000 more. (AHRQ, 2001) 
  • Medication errors cost the U.S. $4 billion a year (Institute of Medicine, 2007) 
  • To put it into perspective, if we extrapolate the IOM’s death statistic (7,000 per year), we can break it down to 583 deaths per month, 134 deaths per week, and 19 deaths per day.

Facts About Medication Errors: The Case for Improved IV Medication Safety. B | Braun USA. Web. Accessed 27 July 2011. Available at:

Mansur JM. Enhanced Medication Safety. The Joint Commission International: Medication Safety Articles. Available at: Accessed 19 Oct. 2011.

“Medication Errors Symptoms, Diagnosis, Treatments and Causes.” Right Web. 3 Oct. 2011. Available at:

Preventing Medical Errors: Report Brief. Institute of Medicine of the National Academies, July 2006. Web. 4 Aug. 2011. PDF available at:

Reducing Medical Errors: Issue Modules, Background Brief., Health Policy Education from the Henry J. Kaiser Family Foundation. May 2008. Accessed 3 Oct. 2011. Available at:

What You Can Do To Avoid Medication Errors. Institute of Medicine of the National Academies. Committee on Identifying and Preventing Medication Errors, Institute of Medicine, July 2006. PDF available at:


Wrong-site Surgery

Wrong-site surgery (WSS) is a term for a medical error resulting in procedures being performed at the wrong site, procedures performed on the wrong person, incorrect procedures being performed at a site and procedures which are more invasive than intended. Causes vary, but some are cited by the Joint Commission as risk factors because of their prevalence in cases where WSS occurred. These include time constraints (caused by emergency surgery or a full schedule), room or staffing changes, multiple procedures being performed and patient characteristics such as obesity or physical deformities which prompted a change in OR setup.

WSS is rare and preventable, but it does still occur. Between 1995 and 2010, 956 wrong-site incidents were reported to the Joint Commission, approximately 13.4 percent of all events reviewed. However, these numbers are believed to represent only 10 percent of actual occurrences as reporting to TJC is voluntary. One study surveyed surgical procedures from 28 hospitals and found the incidence of WSS to be approximately 1 in 112,994 procedures. For the average hospital, this means only one error every 5-10 years. This study also surveyed the costs of these incidents to the hospitals. The median payment to the patient was $12,000 and the cost of defense was $1500, for a total of $13,500 per case on average.


Clarke, John R., Janet Johnston, Mary Blanco, and Denise P. Martindell. “Wrong-Site Surgery: Can We Prevent It?” Advances in Surgery [Adv Surg], ISSN: 0065-3411, 42 (2008): 13-31. Abstract available at:

Gallagher, T. H. “A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery: Review of Medical Error.” JAMA: The Journal of the American Medical Association 302.6 (2009): 669-77. PDF available at:

Stahel P et al. Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era: Analysis of a Prospective Database of Physician Self-Reported Occurrences. Arch Surg. 2010;145(10):978-984. doi:10.1001/archsurg.2010.185. Available at: Accessed 19 Oct. 2011.

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