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State patient-safety commission cites pressure injuries and falls as leading reportable events
Summary
The New Hampshire Health Care Quality and Patient Safety Commission presented its 2024 annual report to the oversight committee, reporting a modest statewide decline in total adverse events but continued prominence of hospital-acquired pressure injuries, patient falls and surgical events and recommending standardized analysis and benchmarking.
Representatives of the New Hampshire Health Care Quality and Patient Safety Commission briefed the Health and Human Services Oversight Committee on Sept. 26 and presented the commission's 2024 annual report and related adverse-event data collected by DHHS.
Chris Herring, vice president for quality improvement at the Foundation for Healthy Communities and chair of the commission, and Hannah Sharp, patient safety officer at Elliot Health System and commission chair, described the commission's voluntary membership (26 acute care hospitals, specialty hospitals and ambulatory surgery centers) and its work to investigate serious reportable events and share best practices under statutory confidentiality protections.
The commission said the statewide total of serious reportable events decreased from 149 in 2023 to 142 in 2024. Doreen Shockley, manager of the Bureau of Licensing and Certification at DHHS, gave the numeric breakdown: pressure injuries (HAPIs) rose from 61 in 2023 to 68 in 2024, falls increased from 37 to 42, and surgical events decreased over the same period. Shockley said the department samples and reviews more than 10% of reported adverse events and obtains root-cause analyses and corrective-action plans from facilities.
Commission members described a year of focused work on hospital-acquired pressure injuries. "Hospital-acquired pressure injuries continue to be the most frequent reported serious reportable event in New Hampshire by far," Sharp said; the commission formed a HAPI work group that performed a common-cause analysis across reported events and developed a standardized root cause analysis and corrective-action plan template for statewide use.
Committee members pressed the commission on how to interpret year-to-year changes. Senator Greg recommended including trend lines and population- or volume-normalized rates in future reports so that readers can distinguish increases driven by reporting or patient-volume changes from true rate changes. Commission staff said they would provide additional context in future reports, noting that patient-volume and surgical-volume increases can affect counts and that some year-to-year variation reflects greater reporting after work on just culture and near-miss reporting.
The commission urged continued collaboration between the commission, DHHS and hospitals and said it will continue to pursue projects on fall prevention, diagnostic safety, retained surgical objects and integration of emerging technologies into safety work.
Committee members requested the datasets and asked the department to consider normalized rates (events per patient days or procedures) in follow-up materials.
