by John R. Fischer
, Senior Reporter | October 02, 2023
Leading up to the launch of a new database in Maryland for tracking patient safety incidents, a data review by the Washington Post has revealed errors in the last three years at the state’s 62 hospitals have more than tripled, resulting in 769 preventable patient deaths and injuries.
Between 2019 and 2022, the level of harm was the highest it has been since the state began collecting patient safety data in 2004, reported the Post
. Incidents included operations on wrong body parts; neglecting mentally unstable patients, resulting in escapes, harm, or death; administering unsafe medication doses in premature babies; and errors leading to amputations.
Incidents are likely to be higher due to a ransomware attack in December 2021 on a Maryland Department of Health server that prevented the Office of Health Care Quality from adding new data and made the public unaware of increases in deaths and injuries for months.
According to the analysis, adverse events were underestimated before due to controversial practices in Maryland and other state and federal healthcare systems. Here is a breakdown:
- No mandatory reporting: Due to privacy concerns and public scrutiny, the state does not require hospitals to disclose adverse events, instead encouraging voluntary reporting, unless a patient is killed or seriously disabled. State and federal regulators also do not closely track many key indicators of systemic problems, and the state does not say where harm occurred or make investigations public.
For every major error reported, experts say dozens of smaller ones go undocumented. “Hospital systems are not all that great at learning from their mistakes. It’s sad to say, but a lot of their mistakes are still buried,” Patient Safety America founder and CEO John James told the Post.
- Rarely fines: While the state can issue civil fines for serious or repeated safety failures, it rarely does and often returns them to hospitals on the promise that they are invested in patient safety.
- Tracks fewer measures: Since the 2021 ransomware attack, the state health department has not been able to track as many metrics. It could not say how many Marylanders died in 2022 because of hospital mistakes. The number was 86 in 2021, nearly double the year prior.
In the wake of the attack, it created a new spreadsheet but does not document prognosis; basic details such as where and when events took place; or if hospitals inform patients and their families of adverse events. It also did not track certain metrics before the attack.
Donald Berwick, a former Centers for Medicare and Medicaid Services administrator and founding CEO of the Institute for Healthcare Improvement, says hospital administrators and boards are responsible for fixing these issues. “The safety community at large is concerned that even pre-pandemic, and during the pandemic, a lot of hospital leaders may have taken their eye off the ball.
The state health department denied the Post’s requests for records on adverse events, and the state would not release investigative data that is off limits to the public.
The new database is expected to be ready this fall. Governor Wes Moore says his administration is working to identify missing data for 2022, including patient deaths, from available records and will share the information as soon as possible.