The Kopec Law firm provides this article summarizes the key findings and recommendations from the Maryland Hospital Patient Safety Program (MHPSP) Annual Report for State Fiscal Year 2023 (FY23). Significantly, instances of medical malpractice resulting in serious injury of death in Maryland increased by 5 percent in 2023.

The Maryland Hospital Patient Safety Program’s Annual Report for Fiscal Year 2023, the 19th year of the program, highlights a concerning trend of increasing adverse events, a persistent “after effect of the COVID-19 pandemic”. The report stresses the need for a “total systems approach” to patient safety to address vulnerabilities like poor processes, workforce challenges, and a lack of transparent, just culture.

Key Findings from FY23 Data – Medical Malpractice Increase

The report indicates a continued increase in event reporting since 2020.

• Total Events: Hospitals reported 957 adverse events in FY23, with 808 meeting the criteria for a Level 1 event (resulting in death or serious disability).
• Level 1 Increase: Reported Level 1 events increased by 5% from the previous year.
• Deaths: Hospitals reported that 118 of the Level 1 events resulted in death, although they attributed only 49 of those deaths directly to the reported event.
• Top Event Classifications: In FY23, 80% of all events fell into five categories: Hospital Acquired Pressure Injuries (HAPIs), Falls, Delays in Treatment, Retained Foreign Objects, and Medication Errors. Pressure injuries, falls, and delays in treatment have been the top three most frequent events since the pandemic began.

Medical malpractice increase:

Focus Areas for Improvement

The report aligns with the national movement, following the Declaration to Advance Patient Safety released by the National Steering Committee for Patient Safety (NSC). The MHPSP emphasizes four functional areas for improving safety: Culture, Leadership, and Governance; Workforce Safety; Patient and Family Engagement; and Learning Systems.

Workforce Safety Challenges

Burnout, depression, and a declining workforce pose a significant threat to patient safety.

• Burnout: Surveys indicate that up to 76% of healthcare workers nationally report burnout.
• Staffing Crisis: In Maryland, one in every four hospital nursing positions is vacant. Furthermore, 62% of Maryland Board of Nursing licensees have considered leaving nursing due to burnout, feeling overworked, and unappreciated.
• Violence: Healthcare workers are the second highest occupation to experience workplace violence, second only to law enforcement. The Joint Commission (TJC) now requires organizations to enforce a workplace violence prevention program.

The Call for a “Just Culture”

The MHPSP advocates for a Just Culture, a system of shared accountability for medical malpractice increase that focuses on improving the system rather than punishing individuals for human error. Key recommendations include:

• Empowerment: Ensure a workforce environment where staff feel empowered to speak up at every level.
• Accountability: Organizations are accountable for the system and working environment, while staff are accountable for their actions.
• Response to Behavior: Human error is met with consolation, at-risk behavior is coached, and reckless behavior is disciplined.

Common Causal Factors in Adverse Events

The report delves into common factors identified in the Root Cause Analyses (RCAs) of the medical malpractice increase of top Level 1 events:

• Hospital Acquired Pressure Injuries (HAPIs): Common factors include failure to turn and reposition patients, failure to use preventative measures like barrier creams or offloading devices (e.g., specialty beds), and failure to assess skin under medical devices.
• Falls: These events are often associated with inaccurate assessment of patient risk, lack of tailored interventions, and failures in communication. An RCA example highlighted a fatal fall where a patient was inaccurately assessed as a standard fall risk despite having diagnoses and comorbidities that made them high-risk.
• Retained Foreign Objects (RFO): These events, which accounted for 52% of Level 1 surgical events in FY23, often occur due to a failure to count all equipment pieces, such as clamps, in addition to sponges and cloths.
• Delays in Treatment: An RCA example showed a delay in treating a patient with a heart attack due to a nurse call-out, leading to a patient with an evolving STEMI not having an assigned nurse, delayed medication, and failure to communicate further EKG changes to the cardiologist.
• Medication Errors: These are frequently caused by failing to follow the “five rights” of administration (patient, drug, dose, route, time) and system and process failures, particularly those related to inaccurate medication reconciliation.

The MHPSP’s overarching recommendation is to prioritize safety using a total systems approach and align with the strategies proposed by the NSC to strive for zero harm across the state.

Medical Malpractice Increase Victim?

If you have been injured by medical malpractice, contact Baltimore medical malpractice lawyer Mark Kopec.

Mark Kopec is a top-rated Baltimore medical malpractice lawyer. Contact us at 800-604-0704 to speak directly with Attorney Kopec in a free consultation. The Kopec Law Firm is in Baltimore and helps clients throughout Maryland and Washington, D.C. Thank you for reading the Baltimore Medical Malpractice Lawyer Blog.