Serious incidents on rise at Massachusetts acute care hospitals

Boston Statehouse

BOSTON (SHNS) – Acute care hospitals in Massachusetts reported an 11 percent increase in a set of preventable incidents affecting patient health in 2020, driven largely by a jump in bedsores, public health officials said Wednesday.

The number of “serious reportable events,” defined under state law as occurrences at hospitals that result in adverse patient outcomes and are influenced by the facility’s procedures, at acute care hospitals increased from 1,189 in 2019 to 1,321 in 2020, according to data presented at a Public Health Council meeting.

A range of incidents fall under the serious reportable event umbrella, including death or injury related to contaminated drugs, surgeons leaving objects in patients after operations, and falls causing serious injury or death. Health officials tracked about 80 more serious reportable events involving stage 3, stage 4 or unstageable pressure ulcers, sometimes known as bedsores, in 2020 than they did in 2019, the data show.

Some of those are likely preventable, Department of Public Health Director of Clinical Quality Improvement Katherine Fillo told the council. Other reportable events that increased year-over-year include suicide or self harm with serious injury events (38 in 2019, 58 in 2020) and physical assault or abuse causing serious injury to a patient or staff member (45 in 2019, 67 in 2020).

Despite the increase at acute care hospitals, the numbers at non-acute care hospitals stayed relatively flat with 146 in 2019 and 144 in 2020. Ambulatory surgical centers did not report a single such incident in 2020 and incidents involving surgery or invasive procedures dropped, Fillo said, reflecting stretches during the COVID-19 state of emergency when non-essential and elective invasive procedures were suspended.

“Better reporting is one of the reasons we’re seeing increases,” she said. “We certainly, though, still do see opportunities for improvement in how health care is delivered. We always are looking at any disparities.”

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