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  • Publication # 13-RA010

Multiple patient safety problems infrequently occur during one single hospitalization but are far more resource-intensive

Patient Safety and Quality

Many studies have documented the occurrence of different types of patient safety problems in hospitals. However, it is uncommon for a patient to experience multiple patient safety problems during one single hospitalization, according to a new study. The team of RAND Corporation researchers found that multiple patient safety events (MPSEs) occurred in approximately 1 in every 1,000 hospitalizations and affected more than 30,000 patients in 2004. 

The vast majority of hospital admissions involved no MPSEs; about 2 percent involved one safety event, and 0.1 percent met the criteria for an MPSE. Among MPSE admissions, the most common type of adverse event was Patient Safety Indicator number 4—failure to rescue (from complications of hospital care), occurring in about half of all such cases.

MPSEs were also remarkable for being associated with higher rates of several other specific categories of adverse events, most frequently postoperative pulmonary embolism or deep vein thrombosis and postoperative respiratory failure. Risk factors for MPSEs included older age, male sex, black race, and residence in a low-income Zip code. The occurrence of MPSEs also was significantly associated with some hospital characteristics, notably including admissions to urban teaching hospitals and to hospitals with a relatively high volume of discharges. Compared with all admissions, the average length of stay for MPSE admissions was four times longer, and the average charge for MPSE admissions was eight times greater.

The study concluded that, despite their low prevalence, MPSEs have distinct characteristics and are far more resource-intensive than hospital admissions generally. This study was supported by AHRQ (Contract No. 290-02-0010). 

See "Multiple patient safety events within a single hospitalization: A national profile in U.S. hospitals," by Hao Yu, Ph.D., Michael D. Greenberg, J.D., Ph.D., Amelia M. Haviland, Ph.D., and Donna O. Farley, Ph.D., in the American Journal of Medical Quality 27(6), pp. 472-479, 2012.


Page last reviewed July 2013
Internet Citation: Multiple patient safety problems infrequently occur during one single hospitalization but are far more resource-intensive: Patient Safety and Quality. July 2013. Agency for Healthcare Research and Quality, Rockville, MD.


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