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Study: Every 1.7 minutes a Medicare beneficiary experiences a patient safety event

GOLDEN, Colo. (April 7, 2009) The 2009 HealthGrades Patient Safety Excellence Award recipients were identified in a report issued today by the leading independent healthcare ratings organization. These hospitals represent an elite group that save lives, save money and prevent errors at a higher rate than other U.S. hospitals.

If all hospitals performed at the level of Patient Safety Excellence Award hospitals, approximately 211,697 patient safety events and 22,771 Medicare deaths could have been avoided while saving the U.S. approximately $2.0 billion from 2005 through 2007. Between 2005 and 2007, 913,215 total patient safety events were recorded among Medicare beneficiaries, which represents 2.3 percent of the nearly 38 million Medicare hospitalizations. This equates to one reported patient safety event every 1.7 minutes.

For the sixth consecutive year, HealthGrades has analyzed patient safety among Medicare patients in all of the nearly 5,000 U.S. non-federal hospitals based on 15 indicators of patient safety developed by the federal government's Agency for Healthcare Research and Quality (AHRQ).

This year, 242 hospitals, which represent the top five percent of all hospitals in the U.S., were recognized with a HealthGrades 2009 Patient Safety Excellence AwardTM. HealthGrades developed this award to give patients more information about choosing a hospital.

"Patient safety incidents are one of the leading causes of death in the U.S. The sad fact is that many, if not most, of these errors are preventable. Patients shouldn't die or experience unnecessary harm as a result of medical errors in hospitals," said Rick May, MD, senior physician consultant at HealthGrades and co-author of the study. "The good news is that there are hospitals that are doing an amazing job when it comes to patient safety and we commend them. Patients need to know that they have a substantially lower risk of experiencing a medical error and therefore a lower risk of death or complications when they are admitted to one of these exceptional top-performing hospitals."

Study highlights:

Large Safety Gaps Identified Between Top and Bottom Performing Hospitals

  • Patients treated at top-performing hospitals had, on average, a 43% lower chance of experiencing one or more medical errors compared to the poorest-performing hospitals.

Patient safety events are common at U.S. hospitals

  • Between 2005 and 2007 there were 913,215 total patient safety events among Medicare beneficiaries.

Common Patient Safety Events are Very Costly

  • Between 2005 and 2007 these patient safety events were associated with over $6.9 billion of wasted healthcare cost.

Less Improvement Seen Among Most Common Events

  • Eight patient safety indicators showed improvement while seven indicators worsened in 2007 compared to 2005. Some of the most common and most serious indicators worsened, including decubitus ulcer (bed sores), sepsis, respiratory failure, deep vein thrombosis (blood clots in the legs), and pulmonary embolism (potentially fatal blood clots forming in the lungs).

Approximately One-in-Ten Medicare Patients with Patient Safety Events Died

  • Between 2005 and 2007 there were 97,755 actual inhospital deaths that occurred among patients who experienced one or more of the 15 patient safety events.

HealthGrades' individual hospital ratings can be viewed for free at


The sixth annual HealthGrades Patient Safety in American Hospitals Study applies methodology developed by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality to identify the incident rates of 15 patient safety indicators among Medicare patients at virtually all of the nation's nearly 5,000 nonfederal hospitals. Additionally, HealthGrades applied its methodology using 12 patient safety indicators to identify the best-performing hospitals, or HealthGrades Patient Safety Excellence Award Hospitals, which represent the top five percent of all U.S. hospitals.

The following are the patient safety indicators studied:

  • Complications of anesthesia
  • Death in low mortality Diagnostic Related Groupings (DRGs)
  • Decubitus ulcer (bed sores)
  • Death among surgical inpatients with serious treatable complications
  • Iatrogenic pneumothorax
  • Selected infections due to medical care
  • Post-operative hip fracture
  • Post-operative hemorrhage or hematoma
  • Post-operative physiologic and metabolic derangements
  • Post-operative respiratory failure
  • Post-operative pulmonary embolism or deep vein thrombosis
  • Post-operative sepsis
  • Post-operative abdominal wound dehiscence
  • Accidental puncture or laceration
  • Transfusion reaction


Contact: Scott Shapiro

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