What Are the Top Medical Errors in New Hampshire Hospitals?

Tracking medical errors and patient harms in New Hampshire acute care hospitals and ambulatory surgical centers

New Hampshire hospitals and ambulatory surgical centers (ASCs), (with the exception of New Hampshire Hospital) are required by law to report all Serious Reportable Events (SREs), as defined by the National Quality Forum’s (NQF) Serious Reportable Events in Health-2011 Update: A Consensus Report. 

The NQF has identified 29 Serious Reportable Events, also called “never events,” which are the basis for state mandatory reporting systems intended to identify and measure events that are considered preventable and of interest to the public and other stakeholders. Identifying and tracking these medical errors and patient harms is an important step in improving patient safety.

 

New Hampshire Serious Reportable Events 2010-2023

According to the NH report based on 2023 data, the increase in adverse events reported from previous years is attributed in part to the ongoing collaboration between the New Hampshire Healthcare Quality and Safety Commission, working to reinforce the importance of reporting and indirectly promote a safe and strong reporting culture by hospitals and ASCs. The report further cautions, that consumers should not "compare the quality of care and safety of the facilities by the number or types of SRE reported. Consumers need to look at all factors such as size of the facility, scope, and complexities of the procedures as well as the number of procedures performed at the facility."

According to the report, the three most common hospital errors in New Hampshire account for 83 percent of all SREs documented. 

• Falls - 25%  
• Pressure Injuries - 41%
• Surgical Events - 17%

Download the full report which details the specific never events at each NH hospital and surgery center. 

We will update you with new data as it becomes available. 

Lubin & Meyer PC - New Hampshire's Leader in Medical Malpractice Law

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NH Hospitals: 64 Adverse Events Reported to DHHS in 2015

About a year ago we highlighted a Report on Medical Errors at NH Hospitals and the excellent coverage by InDepthNH.org, which ran a series of articles on the 29 adverse events — or medical errors — that New Hampshire hospitals are required to report to the Department of Health and Human Services. That reporting detailed the latest data from 2014.

Late last year, 2015 adverse reporting data was released, and again covered by InDepthNH.org.

State Law Requires New Hampshire To Track 29 Hospital Errors That Are Never Supposed To Happen... https://t.co/MONcZK9tfi #NH #patientsafety

— Lubin & Meyer PC (@LubinandMeyer) November 30, 2016

This post is a brief update to last year's report with a link to the full NH DHHS report. To see which NH hospitals reported which adverse events, click on this link: NH Adverse Event Reporting.

NH Adverse Events Decrease, More Improvement Needed

By definition, these events must be “largely, if not entirely, preventable.” There were 64 such events in NH hospitals in 2015.

Number of preventable serious events at NH hospitals from 2010-2015.

 

Breakdown of adverse events: 10 surgical events, 21 falls, 22 pressure ulcers; 11 other

For a list of the 29 hospital errors that must be reported (also known as "never events"), see our previous post which provides a full list of the types of unwanted hospital events.

Lubin & Meyer PC - New Hampshire's Leader in Medical Malpractice Law

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Report on Medical Errors at NH Hospitals

A series of articles on the reporting of adverse events — serious medical errors also known as "never events" — by NH hospitals is available at: InDepthNH.org. There are 29 types of errors — all considered to be avoidable mistakes — that hospitals must report to the Department of Health and Human Services. (See the full list below.)

The most recent data from 2014, shows 73 never events were reported. These include 25 patient falls and 22 pressure ulcers, as well as 14 surgery-related errors at NH hospitals including Catholic Medical Center, Concord Hospital, Mary Hitchcock Memorial Hospital, and Portsmouth Regional Hospital.

How did your hospital do? See the full public document listing the type of adverse events reported by each NH hospital at this NHDHHS web page.

Serious Medical Errors Plague Hospitals in NH https://t.co/wmklmgtJQo via @nancywestnews

— Lubin & Meyer PC (@LubinandMeyer) March 10, 2016

What Are Never Events?

Here is the list of 29 adverse events that hospitals in NH must report in an effort to reduce medical errors and improve patient safety, as reported by Nancy West at InDepthNH.org

Surgical or invasive procedure events

• Surgery or other invasive procedure performed on the wrong site
• Surgery or other invasive procedure performed on the wrong patient
• Wrong surgical or other invasive procedure performed on a patient
• Unintended retention of a foreign object in a patient after surgery or other invasive procedure
• Intraoperative or immediately postoperative/post procedure death in an ASA Class 1 patient

Product or device events

• Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting
• Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
• Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting

Patient protection events

• Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
• Patient death or serious injury associated with patient elopement (disappearance)
• Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting

Care management events

• Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
• Patient death or serious injury associated with unsafe administration of blood products
• Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting
• Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
• Patient death or serious injury associated with a fall while being cared for in a healthcare setting
• Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting
• Artificial insemination with the wrong donor sperm or wrong egg (updated)
• Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
• Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results

Environmental events

• Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting
• Any incident in which systems designated for oxygen or other gas to be delivered to a patient contain no gas, the wrong gas, or are contaminated by toxic substances
• Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting
• Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting

Radiologic events

• Death or serious injury of a patient or staff associated with the introduction of a metallic object into the M RI area

Potential criminal events

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient/resident of any age
• Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting
• Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting

Lubin & Meyer PC - New Hampshire's Leader in Medical Malpractice Law