but not included in the study report, is not encouraging from a global
public health perspective. According to the analysis by HealthGrades,
the overall PSI rate for all Medicare patients in 2003 was 2.7947%. By
2005, it was 3.0199%. That's an increase of nearly 8.1%. In addition,
incident rates for 10 of the 16 specific PSIs worsened from 2003 to
2005, and those 10 that worsened were on average 11.5% worse, the
Just three types of incidents accounted for nearly 72% of all
reported PSIs, with "failure to rescue" leading with an incident rate
of 134 per 1,000 "at-risk hospitalizations." Data was available on
changes in these specific metrics between 2003 and 2005, with failure
to rescue rates dropping (improving) nearly 6%, or eight fewer deaths
per 1,000. The other two most common PSIs were decubitus ulcer, 32 per
1,000 at-risk hospitalizations, which increased (worsened) by 18%; and
post-operative respiratory failure, 15 per 1,000, which increased
(worsened) by 9%.
The news isn't all bad, but progress is slow. Major improvements will necessitate greater changes in care delivery on the part of hospitals, and substantially better and safer products from vendors. The environment at the point of care in many hospitals is inherently unsafe from too many distractions, interruptions, inadequate alarm notification, surveillance, and alarm fatigue.
The growing divide between the top and bottom patient safety performers shows that things can improve. You can down load your own pdf of the study here.