Page 22
the death of tens of thousands. The cost associated with these errors in lost income, disability, and healthcare costs is as much as $29 billion annually. In a study on hospital pneumonia rates and sepsis rates (Eber, et. al , 2010), researchers looked at data from 59 million discharges, covering 40 of the 50 US states between 1998 and 2006. Patients who developed sepsis after surgery had to stay in the hospital on average nearly 11 days extra, at a cost of $32,900 per patient. Just under 20% of these patients died. Pneumonia patients stayed in the hospital an extra 14 days after surgery, at a cost of $46,400, and more than 11% of those patients died. In the State of Florida, registered nurses and licensed practical nurses must complete 2 hours of continuing education related to the Prevention of Medical Errors in each 2-year licensure renewal period. Access Continuing Education, Inc. is a Florida-approved provider of continuing education for nurses, provider # 50-7628. Successfully completing this course will meet the Florida Board of Nursing requirement. Scope of the Problem Since the 1999 IOM report was issued, the issue of patient safety has been in the forefront of the healthcare literature, with multiple healthcare organizations putting significant resources into safety interventions. According to the national study, Third Annual Patient Safety in American Hospitals Study (p. 4, 2006): · Approximately 1.24 million total patient safety incidents occurred in almost 40 million hospitalizations in the Medicare population. These incidents were associated with $9.3 billion of excess cost during 2002 through 2004. For the second year in a row, patient safety incidents have increased - up from 1.14 and 1.18 million reported in the First and Second Annual Patient Safety in American Hospitals studies, respectively. · Of the 304,702 deaths that occurred among patients who developed one or more patient safety incidents, 250,246 were potentially preventable. 9 · Medicare beneficiaries that developed one or more patient safety incidents had a one-in-four chance of dying during the hospitalization during 2002-2004. This rate remains unchanged since the first study was released July 2003. · Wide, highly significant gaps in individual patient safety incidents and overall performance exist between the top and the bottom performing states during 2002-2004. · Minnesota, Wisconsin, Iowa, Michigan and Kansas ranked as the top states for hospital patient safety during the period studied. · New Jersey, New York, Nevada, Tennessee and District of Columbia, ranked last for hospital patient safety during the period studied. · Compared to the worst state (N.J.), the best state (Minn.) had an overall almost 30-percent lower relative risk of developing one or more of the 13 patient safety incidents in its hospitals. However, performance variation between best and worst state was even more significant with individual patient safety incidents. For example, patients had an almost 92-percent lower relative risk of developing post-operative physiologic and metabolic derangements (post-operative delirium) in the top state compared to the bottom state. · When compared to the Second Annual Patient Safety in American Hospitals study, the rates of six key quality improvement focus areas remained unimproved in 2004. Focus areas include metabolic derangements, post-operative respiratory failure, decubitus ulcer, post-operative pulmonary embolus or deep vein thrombosis, and hospital-acquired infections. These six areas continued to worsen on average by almost 12 percent or more over three years (2002 through 2004). · The patient safety incidents with the highest incidence rates continued to be failure to rescue, decubitus ulcer, and post-operative sepsis. Failure to rescue improved 13 percent during the study period, while postoperative sepsis worsened by almost 25 percent. In July, 2006 the IOM issued another report on errors in healthcare. This report, Preventing Medication Errors, focused specifically on the high rates of medication errors. Most Americans have taken medication at one time or another. It's estimated that in