• David W Bates, David M Levine, Hojjat Salmasian, Ania Syrowatka, David M Shahian, Stuart Lipsitz, Jonathan P Zebrowski, Laura C Myers, Merranda S Logan, Christopher G Roy, Christine Iannaccone, Michelle L Frits, Lynn A Volk, Sevan Dulgarian, Mary G Amato, Heba H Edrees, Luke Sato, Patricia Folcarelli, Jonathan S Einbinder, Mark E Reynolds, and Elizabeth Mort.
• From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.).
• N. Engl. J. Med. 2023 Jan 12; 388 (2): 142153142-153.

BackgroundAdverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted.MethodsWe conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events.ResultsIn a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care-associated infections (11.9%).ConclusionsAdverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.).Copyright © 2023 Massachusetts Medical Society.

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