Most process-of-care events do not harm transplant patients, but they boost costs and lengthen hospital stays
Research Activities, March 2011, No. 367
Efforts to improve quality of care in organ transplantation have focused primarily on adverse events (AEs). However, a broader use of voluntary reporting systems and computerized surveillance tools may help identify process-of-care (POC) events and help rein in unnecessary health care costs over time, concludes a new study.
The researchers distinguished POC events that are related specifically to the organization and delivery of care (e.g., delays in treatments and tests, medication errors, gaps in monitoring, falls, equipment malfunction, etc.) from AEs that evolve from the course of disease and the risks inherent to standard treatment. They divided POC events into three categories: clinical performance, communication, and patient management. A voluntary medical event reporting system, implemented in a large hospital, was used to understand the nature of POC events and their impact on hospital length of stay (LOS) and cost for 1,483 patients who experienced 3,012 hospitalizations related to transplantation in 2005. A total of 466 POC events were reported for 336 hospitalizations involving 301 patients. Only 18.5 percent of these events had an effect on the health of the patients, including minor skin damage, pressure ulcers, phlebitis, intravenous infiltrations, injuries, or metabolic changes requiring unplanned interventions.
The most frequent types of POC events were medication errors, falls, and communication errors that accounted for 67 percent of all reported events. POC events were associated with longer LOS and higher costs, regardless of whether an adverse effect or the need of medical intervention was reported for that event. The researchers concluded that monitoring and prevention of POC events in transplantation should form an integral part of a proactive and efficient patient safety system. This study was supported by the Agency for Healthcare Research and Quality (HS11905).
See "Process of care events in transplantation: Effects on the cost of hospitalization," by Natalia N. Egorova, M.P.H., Ph.D., Annetine C. Gelijns, J.D., Ph.D., Alan J. Moskowitz, M.D., and others in the American Journal of Transplantation 10, pp. 2341-2348, 2010.