Connecticut’s Department of Health (DPH) released its most recent annual report on “adverse events” in October 2012, covering data for the year 2011. The term “adverse events” covers a broad range of incidents in healthcare facilities that result in patient injury or death. Not all adverse events are the result of medical error or malpractice, but most instances of medical error are viewed as adverse events. The report found that the total number of adverse events reported around the state has remained stable for several years, but the types of incidents accounting for the total has fluctuated.
The DPH has required healthcare facilities to report adverse events since 2002. In creating its annual report, it categorizes adverse events by type of event and type of facility making the report. It analyzes adverse events rates at four types of healthcare facility: acute care hospitals, chronic disease hospitals and hospices, psychiatric hospitals, and outpatient facilities like ambulatory surgical or outpatient childbirth centers. The events themselves are organized into seven broad categories, with numerous subcategories: (1) surgical errors; (2) drug- or device-related events; (3) interference by the patient or another person; (4) medication error, drug reaction, other treatment error, or bed sores; (5) burns, falls, shocks, toxic exposure, or other physical injury; (6) criminal activity; and (7) errors occurring in the hospital setting, including surgical injuries, infections, and misreporting of test results.
For the calendar year 2011, the DPH received 271 adverse event reports. This is the highest number received in a single year since at least 2005, a four percent increase over the number reported in 2010, and a two percent increase over 2009. As of the end of 2011, the state has received reports of 1,760 adverse events since it began tracking. The most common category of adverse event, comprising thirty-six percent of the total for 2011, involved falls in healthcare facilities causing a patient’s death or serious injury. Perforations during procedures, including open, laparoscopic, and endoscopic procedures, accounted for over eighteen percent of the total. Pressure ulcers, or bed sores, causing serious injury or death made up nearly fifteen percent of the total.