Despite hospitals’ best efforts, the data indicates that some of the most serious adverse events patients can face are becoming more common, not less.

Many so-called “never” events, such as bedsores, retention of foreign objects in a patient and even sexual assault are on the rise, according to a recent review of reported incidents in California over the past few years.

In the 2008-2009 fiscal year, state hospitals saw a 100% increase in “wrong-patient” surgeries, a 78% increase in bedsores and a shocking 131% increase in sexual assaults.

Other never-events saw modest decreases, including wrong-site surgery (down 10%) and death or serious disability due to medication errors (down 6%).

Some of those increases may be due to better reporting of adverse effects. But the numbers indicate there’s still a long way to go in reducing the risks patients face once they’re admitted to the hospital.

Solutions that have worked to bring down the number of adverse events at some hospitals include:

• pre- and post-surgery checklists to triple-check basics such as the patient’s identity, removal of all surgical implements, etc.
• staff training for recognizing/reporting assaults
• using sponges and other surgical implements that have small metallic strips in them that will show up on X-rays for faster identification if left in a patient
• improved labeling for medications to make it easier to distinguish different names, concentrations, etc.

What else can hospitals do to reduce the number of adverse effects? Share your thoughts in the comments.

Reported events Jan.1 through Sept. 30, 2009:

• Wrong-site surgery — 126
• Unintended retention of foreign body — 97
• Delay in treatment — 94
• Operative/Post-op complications — 79
• Suicide — 72
• Patient fall — 65
• Medication error — 34
• Assault, rape or homicide — 27
• Perinatal death or loss of function — 26
• Patient death or injury in restraints — 9

Since JCAHO started tracking sentinel events in ‘95, more than 6,500 patients have been affected, with 68% of the events resulting in death.