- 504.63 KB]Appendix B (Continued)
Cost of Poor Quality or Waste in Integrated Delivery System Settings
Table 3: Total Incremental Cost and Patient Days Associated with Voluntary Event Reports
| Event Type | Cost per Event | Number of Events | Total Cost | Days per Event | Total Days |
|---|---|---|---|---|---|
| Medication | $913 | 4543 | $4,149,346 | 0.52 | 2364 |
| Treatment | $501 | 4622 | $2,316,702 | 0.25 | 701 |
| Fall | $897 | 1025 | $919,507 | 0.68 | 1162 |
| Equipment | $489 | 635 | $310,808 | 0.25 | 124 |
| Behavioral | $659 | 569 | $375,126 | 0.20 | 238 |
| Loss/Exposure | $552 | 542 | $299,448 | 0.42 | 265 |
| Overall | $749 | 11936 | $8,370,937 | 0.43 | 4854 |
Notes: Total cost and days for each event report type of is calculated by multiplying the type-specific per event estimate by the number events of that type. The total cost and days reported above is the sum of the type-specific total cost and days to reflect the frequency of each event type. The overall cost and days per event estimate reported above in italics is from the initial regressions that did not contain type dummy variables and is not used in the calculation of total cost and days.
Table 4: Distribution of Medication Event Subtypes
| Medication Subtype | Percent of Medication Events | Percent with No Harm |
|---|---|---|
| Omission | 30% | 95% |
| Other | 14% | 86% |
| Wrong Dose | 11% | 95% |
| Wrong Time | 9% | 99% |
| Wrong Drug | 7% | 97% |
| Infiltration/Phlebitis | 6% | 35% |
| Incomplete Documentation | 6% | 98% |
| Wrong Rate | 5% | 94% |
| Wrong Patient | 3% | 99% |
| Narcotic Count Related | 2% | 99% |
| Wrong Solution | 2% | 96% |
| Wrong Route | 2% | 93% |
| Wasted Blood/Blood Products | 1% | 91% |
| Wrong Preparation | 1% | 90% |
| Adverse Reaction | 1% | 49% |
| Contra Indication | 1% | 91% |
Table 5: Distribution of Fall Event Subtypes
| Fall Subtype | Percent of Fall Events | Percent with No Harm |
|---|---|---|
| From Bed | 35% | 82% |
| From Walk/Stand | 34% | 81% |
| From Commode/Toilet | 10% | 78% |
| From Chair/Stool | 8% | 89% |
| Other | 6% | 75% |
| Visitor Fall | 3% | 79% |
| In Hallway | 1% | 82% |
| From Wheelchair | 1% | 100% |
| From Table/Stretcher | 1% | 57% |
| From Shower/Tub | 0% | 80% |
Table 6: Distribution of Treatment Event Subtypes
| Treatment Subtype | Percent of Treatment Events | Percent with No Harm |
|---|---|---|
| Delayed | 27% | 94% |
| Omitted | 26% | 94% |
| Incorrect | 15% | 92% |
| Other | 14% | 90% |
| Procedural Complication | 3% | 52% |
| Wrong Patient | 3% | 89% |
| Count Discrepancy | 3% | 99% |
| Skin Issue | 2% | 51% |
| H&P Issue | 1% | 100% |
| Contamination | 1% | 92% |
| Unattended Delivery | 1% | 95% |
| Wrong Time | 1% | 96% |
| Injury | 0% | 65% |
| Test Discrepancy | 0% | 100% |
| Unexpected Death | 0% | 50% |
| Latex Sensitivity | 0% | 83% |
| Wrong Site | 0% | 100% |
Table 7: Distribution of Equipment Event Subtypes
| Equipment Subtype | Percent of Equipment Events | Percent with No Harm |
|---|---|---|
| Malfunction | 49% | 91% |
| Other | 19% | 89% |
| Not Available | 16% | 88% |
| SMDA Related | 8% | 86% |
| Incorrect | 6% | 97% |
| Improper Disposal | 3% | 95% |
Table 8: Distribution of Behavioral Event Subtypes
| Behavioral Subtype | Percent of Behavioral Events | Percent with No Harm |
|---|---|---|
| Complaint | 35% | 91% |
| Other | 26% | 94% |
| Verbal Abuse | 9% | 98% |
| Physical Abuse/Threat | 8% | 77% |
| Unable to Contact Physician | 6% | 97% |
| Elopement | 4% | 100% |
| Self Inflicted Injury | 4% | 50% |
| AMA | 4% | 100% |
| Suicide Attempt | 2% | 73% |
| Legal Action/Threat of Action | 1% | 100% |
| Trespassing | 1% | 100% |
| Contraband | 1% | 100% |
| Illegal Drugs/Weapons | 0% | 100% |
| Sexual Abuse | 0% | 100% |
Table 9: Distribution of Loss Event Subtypes
| Loss Subtype | Percent of Loss Events | Percent with No Harm |
|---|---|---|
| Lost/Damaged/Stolen | 41% | 98% |
| Other | 35% | 92% |
| Exposure | 13% | 90% |
| Environmental | 10% | 96% |
| Signage Not Used | 0% | 100% |
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