Medicare deaths report cites fatal infections

CMS says "aggressive action" coming

A recent federal report that included the highly publicized finding that some 15,000 Medicare patients die every month due to adverse events and hospital-acquired conditions (HAC) may ratchet up pressure on hospitals to prevent infections, which represented some 15% of the HACs. In addition, hospital care associated with adverse and temporary harm events cost Medicare an estimated $4.4 billion annually, the report by the Department of Health and Human Services' Office of Inspector General (IG) estimated.1

The IG report urged action by the Center for Medicare and Medicaid Services (CMS), noting that based on the findings the "CMS stated that it will 'aggressively pursue' broadening the scope and definition of patient safety efforts to be more inclusive of various types of adverse events and more closely monitor and address hospital quality of care."

That could mean more pressure on reducing HAIs in the form of withheld CMS reimbursements, but the IG report also acknowledged that not all infections are preventable.

Eli Perencevich"I don't know how it is going to [affect] policy, but I think that this is in line with what many of us already feel," says Eli Perencevich, MD, MS, an epidemiologist at the University of Iowa Healthcare in Iowa City. "Basically the report suggested that some of the medical errors are hospital acquired infections and a certain percent of those — some 60% — were preventable.

However, since the report was based on extrapolated data, only 19 infections (three of which were fatal) were actually subject to analysis, Perencevich notes. That makes any broad extrapolations about preventability somewhat suspect in any case, but the bottom-line is that HAIs and other adverse events must be reduced to the extent possible.

"The key thing is that errors are still occurring in hospitals," he says. "Too many are occurring and more efforts need to be made. They found 134,000 adverse events in a single month — that's obviously too many. A subset of those — only 15% of the errors — were attributable to infections."

In general, the report focused on adverse events defined as harm to a patient as a result of medical care, including HACs such as catheter-associated urinary tract infection, vascular catheter-associated infection, blood incompatibility, pressure ulcers and falls. The report included adverse events from relatively minor patient glycemic control problems to serious events that prolonged hospital stay, or caused permanent harm or death. The fatal infections cited included two bloodstream infections and a ventilator associated pneumonia.

The reports used a nationally representative random sample of 780 Medicare beneficiaries from all beneficiaries discharged during October 2008. An estimated 1.5% of hospitalized Medicare beneficiaries experienced events that contributed to their deaths. Among the 128 adverse events that we identified in the sample, 12 events (9% of 128 events) contributed to the deaths of beneficiaries. That projects to an estimated 1.5 % of hospitalized Medicare beneficiaries experiencing events that contributed to death or approximately 15,000 beneficiaries during the study period. In addition to the aforementioned fatal infections, seven patient deaths were related to medication, either the result of improper administration of medication (wrong drug or wrong dosage) or inadequate treatment of known side effects. The most common type of medication-related death (five deaths) involved excessive bleeding from blood-thinning medication. The two other medication-related deaths involved inadequate insulin management resulting in hypoglycemic coma and respiratory failure resulting from over-sedation. Two patient deaths involved aspiration, which led to pneumonia in one case and cardiac arrest in another.

Overall, the IG report used physician reviewers to conclude that 44% of all events were preventable and 51% were not preventable. (For the remaining 5% of events, physicians were unable to make determinations.)

"Events related to surgery or procedures were less likely to be preventable than other types of events, such as hospital-acquired infections," the report concluded. "Preventable events were linked most commonly to medical errors, substandard care, and lack of patient monitoring and assessment. Physician reviewers assessed events as not preventable when they occurred despite proper assessment and care or when the patients were highly susceptible to the events due to health status."

Because many adverse events we identified were preventable, hospitals must reduce their incidence, the IG concluded. "A number of agencies within HHS share responsibility for addressing this issue, most prominently the Agency for Healthcare Research and Quality (AHRQ) as a coordinating body for efforts to improve health care quality and CMS as an oversight entity and the Nation's largest health care payer."

Recommendations for action

The IG report recommended the following:

  • AHRQ and CMS should broaden patient safety efforts to include all types of adverse events. This broader definition would apply to a number of activities, including setting priorities for research, establishing guidelines for hospital reporting, developing prevention strategies, measuring health care quality, and determining payment policies.
  • AHRQ and CMS should enhance efforts to identify adverse events. Identifying adverse events assists policymakers and researchers in directing resources to the areas of greatest need, setting clear goals for improvement, assessing the effectiveness of specific strategies, holding hospitals accountable, and gauging progress in reducing incidence.
  • AHRQ should sponsor periodic, ongoing measurement of the incidence of adverse events.
  • AHRQ should continue to encourage hospital participation with Patient Safety Organizations, entities intended to receive adverse event reports from hospitals, and forward the information to a national AHRQ database.
  • CMS should use Present on Admission Indicators in billing data to calculate the frequency of adverse events occurring within hospitals.
  • CMS should provide further incentives for hospitals to reduce the incidence of adverse events through its payment and oversight functions.
  • CMS should strengthen the Medicare HAC policy, such as by expanding the policy to include more events that harm beneficiaries.
  • CMS should look for opportunities to hold hospitals accountable for adoption of evidence-based practice guidelines.


  1. Office of Inspector General. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. OEI-06-09-00090 Nov. 2010. On the web at: