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2005 National Healthcare Quality Report

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Patient Safety (continued)

Adverse Events and Postoperative Complications of Care

Various adverse events and complications can occur during episodes of care. Although some of the events may be related to a patient's underlying condition, many of them can be avoided if adequate care is provided. Patients are especially vulnerable to adverse events during and right after surgery. In addition, the risk of complications during the performance of medical procedures may, in part, be related to the underlying severity of illness of patients who require procedures such as the placement of central venous catheters (CVCs).

Postoperative venous thromboembolic events. After surgery, patients are at higher risk for developing blood clots in their legs. This risk can be reduced by getting patients to walk as soon as possible after surgery and by giving patients medications and treatments that prevent blood clots.

Figure 3.1. Surgical patients with postoperative venous thromboembolic event, 2002 and 2003

Figure 3.1. Surgical patients with postoperative venous thromboembolic event, 2002 and 2003. Select [D] Text Description for details.

[D] Select for Text Description.

Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2002-2003.

  • From 2002 to 2003, the percentage of surgical patients with postoperative venous thromboembolic events fell from 0.80% to 0.78% (Figure 3.1). This change was not significant.

Postoperative hip fracture. After surgery, some patients may be at risk of falling, which can result in broken bones. This risk can be reduced by raising bed rails, monitoring ambulation, and removing items from the room that could cause a patient to trip.

Figure 3.2. Postoperative hip fracture per 1,000 adult surgical patients, 1994, 1997, 2000-2002

Figure 3.2. Postoperative hip fracture per 1,000 adult surgical patients, 1994, 1997, 2000-2002. Select [D] Text Description for details.

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1994, 1997, 2000-2002.

  • From 1994 to 2002, the rate of postoperative hip fracture among adult surgical patients did not change significantly (Figure 3.2).

Adverse events associated with central venous catheters. Inserting a CVC into the great vessels can result in a number of non-infection adverse events.

Figure 3.3. Central venous catheter placements with associated mechanical adverse events, 2002-2003

Figure 3.3. Central venous catheter placements with associated mechanical adverse events, 2002-2003. Select [D] Text Description for details.

[D] Select for Text Description.

Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2002-2003.

  • From 2002 to 2003, the percentage of CVC placements with associated mechanical adverse events decreased significantly from 3.24% to 2.03% (Figure 3.3).

Iatrogenic pneumothorax. A number of medical procedures can accidentally puncture a lung.

Figure 3.4. Iatrogenic pneumothorax per 1,000 discharges, 1997, 2000-2002

Figure 3.4. Iatrogenic pneumothorax per 1,000 discharges, 1997, 2000-2002. Select [D] Text Description for details.

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1997, 2000-2002.

  • From 1997 to 2002, the rate of iatrogenic pneumothorax decreased from 1.2 to 0.9 per 1,000 discharges (Figure 3.4).

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Hospital-Acquired Bloodstream Infections in ICU Patients Chapter 3. Patient Safety

 

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