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Exploring Vulnerability to Patient Safety Events along the Age Continuum

PIPSQC is pleased to share the recent publication in Pennsylvania Patient Safety Advisory, entitled "Exploring Vulnerability to Patient Safety Events along the Age Continuum." This article analyzed 2017 data submitted to the Pennsylvania Patient Safety Authority to document age-related patterns of patient harm in Pennsylvania hospitals. Of particular note, the highest total event rate per admission was found in the 5- to 14-year cohort (511.12 events per 1,000 admissions) with much lower rates in other cohorts.

The full publication is available online at:
http://patientsafety.pa.gov/ADVISORIES/Pages/201903_EventsbyAge.aspx

ABSTRACT:

To identify age-related patterns of events that could have or did result in unanticipated patient harm, the Pennsylvania Patient Safety Authority developed a data snapshot from more than 260,000 event reports submitted by Pennsylvania hospitals through the Pennsylvania Patient Safety Reporting System during 2017. For almost all age cohorts, the most common event type was Error related to Procedure/Treatment/Test while among Serious Event reports (i.e., event resulting in harm), the most common event type was Complication of Procedure/Treatment/Test. Differences in event report patterns for children, adolescents, and young adults compared with events involving adults and elderly patients were noted. For adults 75 years or older, the number of event reports decreased, while the rate of involvement in a patient safety event report relative to estimated population increased as patient age increased. For adults 25 years or older, the number of reports involving two event types—Fall and Skin Integrity—increased with advancing age. Although the increased rate of total event reports at the extremes of age relative to estimated population was unsurprising, the decreased rate of Serious Events in the very elderly, and the increased rate of total and Serious Events in the age cohort of 5 to 14 years relative to number of admissions were unanticipated. Attention to the event types and patterns of vulnerability that predominate in specific age cohorts may help facilities prioritize interventions.