Hospitals in Maryland are required to report serious adverse events that occur in those hospitals to the Maryland Office of Health Care Quality (OHCQ). OHCQ in turn issues a yearly report regarding the reported hospital errors and mistakes that result in serious injuries or death. The most recent report presently available is for fiscal year 2009 (from July 1, 2008 through June 30, 2009).
Level 1 Adverse Events are the most serious reported adverse events. There were 190 Level 1 Adverse Events reported to OHCQ for fiscal year 2009, up from 183 for fiscal year 2008. The number of Level 1 Adverse Events reported by fiscal year increased for each of the five years that the reporting program has been in effect.
Maryland has 69 licensed hospitals. Of those, 49 reported at least one Level 1 Adverse Event during fiscal year 2009. Of the 69 licensed hospitals, 65 had reported at least one Level 1 Adverse Event in the five years of the program. The larger the hospital and the greater the complexity of the patient population served led to a greater number of reported Level 1 Adverse Events – the largest 16 hospitals as measured by the number of licensed beds accounted for 49% of all reported Level 1 Adverse Events for fiscal year 2009 (hospitals with over 200 licensed beds accounted for 71% of Level 1 Adverse Events). Sixteen acute care hospitals reported more than 20 Level 1 Adverse Events since the reporting requirement began five years prior, averaging between four and nine per year.
Forty four percent (44%) of reported Level 1 Adverse Events occurred in the inpatient rooms and bathrooms of medical surgical units. Twelve percent (12%) occurred in surgical suites. Ten percent (10%) occurred in emergency departments. Nine percent (9%) occurred in psychiatric units in acute hospitals and in psychiatric hospitals. Other locations of Level 1 Adverse Events were in critical care units and in labor and delivery units.
Maryland licensed hospitals include acute general, psychiatric, chronic, rehabilitation, and children’s hospitals. The acute care hospitals account for 68% of all Maryland licensed hospitals but reported 179 of the 190 Level 1 Adverse Events for fiscal year 2009.
The most frequently reported adverse events for fiscal year 2009 were falls, accounting for 52 of the Level 1 Adverse Events. Fourteen of the falls resulted in the deaths of the patients and 56% required surgery. The second most frequently reported adverse events were for delays in treatment, which resulted in the deaths of nine of the sixteen patients. There were seven successful suicides and one suicide attempt that resulted in serious disability. There were nine reports of Stage III and Stage IV pressure ulcers (bed sores) reported from two hospitals during fiscal year 2009. There were 9 reports of healthcare-associated infections during fiscal year 2009, 7 of which resulted in the patient’s death.
Importantly, the annual report from OHCQ acknowledges that the number of Level 1 Adverse Events is under-reported, for various reasons. We suspect that the under-reporting of serious adverse medical events to OHCQ is much higher than alluded to.
If you have been the victim of a medical mistake, medical error, or medical negligence by a hospital in Maryland (or any other state), visit our website to be connected with local medical malpractice lawyers who may be able to investigate your medical malpractice claim for you and represent you, if appropriate. You can also call us toll free at 800-295-3959.
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