Although organizational definitions may vary, an adverse event is typically defined as an undesired outcome or injury, not expected within the normal course of care or delivery of services to a patient or care recipient. Examples of adverse events include patient falls, the development of a facility acquired pressure injury, wrong site surgeries, healthcare associated infections, and medication errors. These adverse events harm patients, negatively impact quality measures, disrupt healthcare service delivery, damage facility reputation, drive up insurance premiums, and can impact staffing recruitment and retention issues within the organization.
According to the American Hospital Association (AHA) there are 6,129 hospitals in the U.S. These facilities reported over thirty-four million admissions in 2023. In addition to acute care facilities there about 1,365 Critical Access Hospitals (CAH) and more than 18,700 skilled nursing facilities (SNF) in the U.S.
The National Institute of Health (NIH) reported an estimated two million adverse events in the U.S. each year. That works out to 5,479 events each day, equal to four events every minute resulting in 100,000 patient deaths each year. Sadly, one in every ten patients is exposed to or suffers a poor outcome associated with an adverse event.
Regulatory bodies including the Centers for Medicare and Medicaid Services (CMS), and the Agency for Healthcare Research and Quality (AHRQ) are part of the U.S. Department of Health & Human Services (HHS) are engaged in research efforts to boost the quality of healthcare, reduce adverse events, and improve patient safety.
The public becomes informed about poor outcomes and facility safety issues through reporting agencies including the CMS, Hospital Consumer Assessment of Healthcare Providers and Systems scores (HCAHPS), Leapfrog, Healthgrades and other public reporting agencies including the U.S News & World Report, the Becker’s Hospital Review, and others.
A lack of mobility during the hospital stay can result in harm to the patient. This decrease in mobility may be related to the disease process, trauma, or a surgical procedure and is commonly known as hospital-acquired weakness. As an example, a patient following surgery may be weak and unable to turn, reposition, or adjust themselves for comfort in bed. Their lack of ability to move is placing them at risk of developing a pressure injury, forming a blood clot, or the onset of pneumonia.
Standards of care, developed by clinical experts, provide guidance that directs the care team to turn and reposition the patient every two to four hours to help prevent the development of a pressure injury. When the care team performs the turn and repositioning activity, they place themselves at risk of a musculoskeletal injury. These Workers’ compensation claims are most often categorized as a back injury and are more likely to occur when resources and lift equipment are scare or not routinely used to complete this high risk for injury care activity. Hospital-acquired weakness, occurring as a result of a lack of mobility is frequently associated with the risk of patient falls and fall-associated injuries. The musculoskeletal and cardiovascular systems become more compromised the longer someone stays in bed. When the patient attempts to get up out of the bed or chair, they may become dizzy and faint, resulting in a patient fall and possible injury like a fractured hip or a head injury.
The University of Michigan conducted a series of studies to identify commonly missed nursing care activities and the reasons the care was missed. The studies identified turning and repositioning patients, and ambulating patients as the two primary care activities, recognized as standards of care that were most often missed. As a result, when patients are not turned, they are more at risk for pressure injuries. Without ambulation, the patient can become weaker and at risk for falls and fall injuries. When standards of care are not met, and adverse events ensue, the organization is at greater risk of litigation and increased costs related to professional liability coverage.
As organizations strive to achieve their goal of enhancing safety and reducing risk for patients, not only do they need to address the workforce shortages, but also the worker’s experience that occurs as a result of the current staffing vacancies.
Employee safety has a measurable impact on patient safety, in fact; the Institute for Healthcare Improvement is quoted as saying, “healthcare workforce safety is inextricably linked to patient safety, outcomes, and experience of care.” In other words, we need to examine the holistic culture and environment of safety in healthcare and address how we plan to keep employees safe while they are at work providing the care the patients need.
For example, when we examine the contributing factors surrounding of an employee injury, we sometimes find a gap in staffing coverage. This gap can be correlated to the time when the incident occurred that required the individual to work overtime possibly resulting in worker fatigue.
Both, shortages, and fatigue, can increase errors in the workplace that in turn impact patient safety and other members of the care team member. The Joint Commission (TJC) issued Sentinel Event Alert 48, outlining the impact of fatigue on workers and the risk that worker fatigue poses to patients, personal safety, and potential injury.
Research is abundant from The Veterans Administration that shows the risk of musculoskeletal injury to the care team that occurs when performing these bedside care activities. Musculoskeletal injuries generally account for 35-37% of the facility's workers' compensation costs. They are a leading cause of back injury that prevents the care team from full duty and returning to bedside patient care.
Worker injuries contribute to workforce shortages as some individuals decide not to return to the workforce and seek out other opportunities for employment. After an injury the worker may have restrictions that temporarily, and sometimes permanently prevent them from performing their role or function at the bedside. Without a vital workforce program in place, the healthcare industry cannot meet their primary objective to provide care and recovery for patients in their facility and community.
Providing safe care and positive patient outcomes are just two of healthcare's primary objectives. The challenge remains for all of healthcare to create an environment with precision policy and practice that protects patients from adverse events while protecting workers from injury. It is time to create a formula that represents a balance of safety for patients without creating potential harm or injury to the worker. Hazards that impact the worker coming as a result of system issues, unused or faulty equipment, fatigue and staffing shortages must be identified and rectified.
Willis Towers Watson hopes you found the general information provided in this publication informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, Willis Towers Watson offers insurance products through licensed entities, including Willis Towers Watson Northeast, Inc. (in the United States) and Willis Canada Inc. (in Canada).
