Adverse Events Coverage Response

October 03, 2023

A week ago The Washington Post ran an article based on the Maryland Department of Health (MDH) Office of Health Care Quality’s (OHCQ) Maryland Hospital Patient Safety Program Annual Report for fiscal year 2022. The report notes a steep incline in self-reported adverse events during COVID-19 with the most significant increases for pressure injuries, falls, and delays in treatment, although the article focused on more serious events.

The Baltimore Sun Editorial Board then published a piece calling for a long-term plan to boost hospital staffing, including calling on the Governor and Health Secretary to set hospital rates that allow higher compensation.

Unfortunately, the Post article takes a complex situation and simplifies it. Some key concerns related to the coverage include:

  • Reported Hospital Acquired Pressure Injuries (HAPI) increased between fiscal years 2020 and 2022, largely due to COVID-19 and an emphasis by MDH OHCQ on updated National Quality Forum (NQF) definitions of HAPI from 2021, which dramatically increased the scope of reporting. This emphasis on reporting standards resulted in HAPI being the major driver of the increase in total Level 1 adverse event reports, accounting for nearly two-thirds of the total increase. Under the new reporting standards, hospitals now include level 3, 4, and unstageable HAPI as a level 1 adverse event alongside more serious events that cause death or serious disability. The Post article is misleading because the major drivers behind the perceived increase were minor events and changes in reporting standards. There was also a two-year gap in distribution by MDH, eliminating incremental increases. Finally, the data set is not full and has not been normalized.
  • Maryland is one of only 27 states nationally with extensive reporting requirements for adverse events. We have a different environment than the rest of the country. We’re under more oversight, we practice more transparency, and we have strong systems in place to identify events and remedy them.
  • These adverse events are self-reported. Maryland hospitals track these events to understand them, address concerns, and prevent them in the future. A strong culture of patient safety and transparency requires that hospitals identify these issues. This can result in perceived higher instances in our region compared to other states that do not report.

This is all to say that MHA is engaged in responding to the stories, will be meeting with MDH to review the data, and will continue conversations with MDH and patient safety organizations, like the Maryland Patient Safety Center, along with all of you as we determine next steps.

Your MHA Team

  • Blog
  • 2023