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Incidence of adverse events in Indian Health Service hospitals
Incidence of adverse events in Indian Health Service hospitals
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Report in brief (United States. Department of Health and Human Services. Office of Inspector General)
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
- Publication:
- Washington, D.C. : U.S. Department of Health and Human Services, Office of Inspector General, December 2020
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Government Regulation
Hospitals, Public -- statistics & numerical data
Patient Harm -- statistics & numerical data
United States
United States. Department of Health and Human Services
United States. Indian Health Service - Genre(s):
- Technical Report
- Abstract:
- Why OIG Did This Review. The Office of Inspector General (OIG) conducted this review to estimate the incidence of patient harm events in Indian Health Service (IHS) hospitals and to assess the extent to which these events were preventable. IHS provides comprehensive Federal health services to approximately 2.6 million American Indians and Alaska Natives. In fiscal year (FY) 2017, IHS provided acute-care services at 26 hospitals located predominately in remote areas across the country. Most of these hospitals are small, with few inpatient beds. Compared to acute-care hospitals nationally, IHS hospitals have lower patient volume, provide less clinically complex care, and have shorter average lengths of stay. Prior OIG reports have identified longstanding challenges to IHS’s ability to deliver safe and high-quality health care to American Indians and Alaska Natives—a medically vulnerable population with poorer health outcomes and barriers to accessing health care, especially among those aged 65 and older. Challenges faced by IHS hospitals include staffing shortages and lack of specialty care. IHS hospitals in the agency’s Great Plains Area are a location of particular concern for these issues. This report is part of an OIG series of reports about adverse events in health care settings and continues OIG’s commitment to monitoring the quality of care at IHS facilities. How OIG Did This Review. We selected a stratified random sample of 400 patients, from pediatric patients to older adults, who were admitted to 1 or more of the 26 IHS hospitals during FY 2017. The final sample consisted of 384 patients because of a small number of ineligible admissions and missing records. We drew patients for our sample from six strata that were based on hospital location and size. This sample design enabled us to ensure that the sample included a range of small hospitals, that it did not require a high number of records from large hospitals, and that we could make projections to the Great Plains Area. We calculated the incidence rate of patient harm events in IHS hospitals from a review of patients’ medical records. Clinicians reviewed each patient’s medical records to identify patient harm events and to assess the extent to which these events were preventable. We conducted the review in two stages. Stage 1: Nurses screened the records for possible patient harm events using a “trigger tool method.” A “trigger” is a clinical clue—for example, documentation of a fall—that may indicate harm. Stage 2: Physician-reviewers conducted a full review of the records flagged by nurses as containing possible harm events. Physician-reviewers identified harm events and assessed the level of harm, whether events were preventable, and factors that contributed to events.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (61 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 9918283580706676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918283580706676