Medical mistakes that led to either death or severe disabilities are apparently on the rise in Maryland, according to a new report from the state’s Department of Health.

The report, highlighting data from fiscal year 2023, marks the fourth consecutive year that Maryland hospitals have seen an increase in such incidents, starting with the increase in 2020.

In fiscal 2023, the Maryland Department of Health said there were 957 adverse events reported, including 808 Level 1 events.

Level 1 events are described as “an adverse event that results in death or serious disability.” The latest report marked a 5% increase in such incidences, according to the report.

Pressure injuries were the most frequently reported Level 1 event for the latest report, but were down 2% from the previous year. These types of injuries include ulcers, which commonly happen because of failure to turn and reposition patients with limited mobility and offload pressure in hospital beds, the report found.

Medical tubes and devices caused 30% of in-hospital pressure injuries. “Proper positioning and securing of medical tubes and devices is crucial to pressure injury prevention,” the report states.

Falls were the second-most reported event, with a 22% increase from fiscal 2022, according to the report.

The Agency for Healthcare Research and Quality reports that more than one-third of hospital falls result in injury, including serious injuries such as fractures and head trauma.

The state report mentions one fall patient in particular who was transferred from an outside hospital with leukemia. The nursing staff at the hospital assessed the patient as a “standard fall risk,” as they had no prior fall history.

However, that patient was later diagnosed as nonverbal with a subdural hematoma after they hit the back of their head on a closet door while walking to the bathroom, according to the report. At the time of the fall, the patient was reported as having a “sudden urinary and fecal incontinence.”

The report stated that the patient had become nonverbal during CT testing.

An investigation into that incident revealed the patient should have been classified as “high-risk” due to their “diagnosis, comorbidities, and medications,” the report said. Investigators also believe the IV pole was a factor in the fall.

“Since the patient’s risk for falls was not assessed accurately, appropriate interventions were not in place, such as a room closer to the nursing station or the use of a bed alarm,” the report stated.

Delays in treatment are the third-highest reported event, and may happen due to “inadequate assessments, communication failures, or human factors, such as timely diagnostic testing, labs, and imaging.”

The department said the trend of increased medical mistakes could be caused by workforce shortages and residual effects from the pandemic.

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