Maryland’s Alarming Increase in Reported Medical Errors: What It Means for Patient Safety

Maryland’s Alarming Increase in Reported Medical Errors: What It Means for Patient Safety

A recent report outlines yet another increase in reported medical errors across Maryland. State data confirms that medical mistakes leading to serious patient harm are rising, a trend linked to persistent systemic issues. 

The COVID-19 pandemic highlighted numerous weaknesses within the healthcare system, which continue to create conditions conducive to adverse events.

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The Factors Behind Maryland’s Patient Safety Crisis

The recent Maryland Hospital Patient Safety Program annual report highlights a troubling reality for patients. In fiscal year 2023 alone, hospitals across the state reported 957 adverse events, including 808 Level 1 events—the most serious category, involving outcomes such as death or permanent disability. 

This marks the fourth consecutive annual increase in reported medical errors, underscoring a healthcare system under immense strain. These numbers aren’t abstract metrics; they represent real individuals and families whose lives have been irrevocably altered by preventable mistakes.

The report directly links this upward trend to the lingering aftershocks of the COVID-19 pandemic, which continues to shape the state’s healthcare landscape. 

The crisis exposed deep vulnerabilities within the system—staffing shortages, high patient acuity, and supply chain disruptions—that still affect care quality in facilities.

Workplace Stress and Fatigue

Workforce fatigue remains a central issue. Surveys cited in the report reveal that nearly half of all physicians and over 75% of nurses experience burnout or high stress. 

When clinicians are overextended and undersupported, the likelihood of errors rises—a reality reflected in the 118 patient deaths linked to Level 1 events in FY 2023, 49 of which were directly attributed to medical mistakes. 

These statistics paint a sobering picture: a healthcare workforce under pressure and a system struggling to deliver the safe, timely care every patient deserves.

Adverse Events in Maryland’s Hospitals

Maryland law outlines a specific system for classifying harm caused by medical treatment. An "adverse event" is defined as an unexpected occurrence related to a patient's medical care, not the natural progression of their illness.

This classification system helps regulators and hospitals track the frequency and severity of mistakes. By understanding these categories, patients can better contextualize their own experiences within the broader patient safety landscape. 

The system is broken down into three distinct levels of severity:

• Level 1 Events: These events are the most severe classification and result in a patient's death or a serious disability. A serious disability refers to a physical or mental impairment that significantly restricts at least one major life activity. This impairment must persist for more than seven days or still be present at discharge.
• Level 2 Events: A Level 2 event is a grave mistake requiring medical intervention to prevent a patient from dying or suffering a serious disability. In these situations, harm was imminent, but the medical team was able to act in time to stop the worst possible outcome. While the patient may still suffer harm, this classification acknowledges that quick action prevented a Level 1 tragedy.
• Level 3 Events: These adverse events don’t result in death or serious disability or require any specific medical intervention to prevent such an outcome. While still a failure in the standard of care, the harm caused by a Level 3 event is less severe. However, these events are still important for hospitals to track as they often point to underlying system issues that could lead to more serious errors if left unaddressed.

The Most Common and Damaging Medical Mistakes

While any medical error can cause harm, the state’s report identifies several recurring events that pose a significant threat to patient well-being. The data shows a clear pattern in the types of mistakes that are most frequently reported. 

In fact, roughly 80% of the most severe Level 1 events fell into just five categories in FY 2023. The ongoing increase in reported medical errors demands a closer look at these specific failures.

1. Pressure Injuries

Pressure injuries represented the largest portion of adverse event reports in the 2023 fiscal year. These injuries, also known as bedsores, involve damage to the skin and underlying tissue from prolonged pressure. 

They often occur in patients who are immobile for long periods, such as those in intensive care or with multiple medical conditions.

While hospitals note that better reporting practices have contributed to the documented numbers, these injuries are largely preventable. Although pressure injuries remained the most common event, the total number decreased by about 2% compared to the prior year. 

Proper patient repositioning, specialized mattresses, and attentive nursing care are fundamental to prevention. A failure to follow these established protocols can lead to severe pain, infection, and long-term health complications for the patient.

2. Patient Falls

Falls were the second-most reported adverse event, with a staggering 22% increase from the prior year. A fall in a hospital setting can cause devastating injuries, including broken bones and head trauma, particularly for elderly or frail patients. 

The report identifies specific risk factors that make certain patients more vulnerable.

Common examples include:

• Mobility Challenges: Patients who have difficulty walking or standing on their own require robust support and assistance.
• Cognitive Impairment: Individuals with dementia, confusion, or the effects of medication may not recognize their physical limitations.
• Frequent Toileting Needs: The urgency to use the restroom is a common reason patients attempt to get out of bed without help.

3. Delays in Treatment

The third-most common event, a delay in treatment, can have catastrophic consequences. These delays rose by about 16% compared to the previous year, often resulting from communication breakdowns between medical staff or inefficient workflow processes. 

A patient's condition can change rapidly, and a failure to communicate those changes promptly can lead to missed opportunities for critical tests or life-saving interventions.

The report gives examples of evolving patient conditions not being communicated effectively, leading to harm. For instance, a nurse may notice a subtle change, but that information does not reach the doctor in time to order a necessary scan. 

4. Surgical Errors and Retained Foreign Objects

Surgical errors are among the most preventable mistakes, with unintended retained foreign objects being the most frequently reported type. This happens when surgical tools, sponges, clamps, or other items are left behind inside a patient's body after a procedure. 

These errors are almost always the result of a breakdown in basic safety protocols. In fiscal year 2023, these devastating mistakes accounted for more than half of all the most serious surgical-related errors reported in Maryland.

5. Medication Errors

Medication errors remain a persistent problem in Maryland hospitals. These mistakes can happen at any point, from prescribing to administration. They’re especially common during transitions of care, such as when a patient is transferred between facilities or different hospital departments.

In one reported case, a patient's prescribed medication wasn’t continued after they returned from another facility. This oversight contributed to a serious cardiac event. 

Incomplete patient records or a failure to properly reconcile medications can lead to incorrect dosages, missed medications, or harmful drug interactions. 

Systemic Responses and the Path Forward

In response to the increase in reported medical errors, the Maryland Hospital Patient Safety Program report pushes for broad changes in hospital culture and operations. These initiatives aim to make healthcare safer from the inside out by adopting a total systems approach to patient safety.

This new framework for safety involves several key principles:

• A Just Culture: This approach focuses on improving flawed systems rather than blaming individual employees for mistakes. It recognizes that process failures, not individual negligence, cause most errors. This model differentiates between human error, at-risk, and reckless behavior, enabling coaching and system redesign over automatic discipline.
• Encouraged Reporting: Staff members can report incidents and near misses without fear of punishment, allowing hospitals to identify and correct systemic problems. Transparency helps hospitals identify vulnerabilities before widespread harm occurs. Organizations can analyze these reports to identify patterns and fix the root causes of potential errors.
• Workforce Support: The report urges hospitals to prioritize the physical safety and psychological well-being of their staff as a core component of patient safety. High levels of burnout and stress, as documented in the report, directly correlate with an increased risk of medical mistakes. 

The report makes it clear that patient safety is directly linked to the health of the healthcare workforce. A safe and supported workforce is more resilient and better equipped to manage the high-acuity, complex care that modern patients require.

Unfortunately, these large-scale changes take time to implement across the state. While hospitals work to improve their systems, patients remain vulnerable to the consequences of the current crisis, as the increase in reported medical errors continues.

Maryland’s Trusted Medical Malpractice Law Firm

The news about the increased reported medical errors in Maryland is a call to action for patients to be vigilant. If you suffered harm because of a preventable medical mistake, you don’t have to face the complexities of the legal system alone.

At Furman Honick Law, we help people injured by medical negligence seek the compensation they need. Call our team today at (410) 406-7890 for a confidential consultation.