Harm in Hospitals Seldom Reported, OIG Says
By Emily P. Walker, Washington Correspondent, MedPage Today
Published: January 06, 2012
WASHINGTON -- Most hospital errors that result in harm to Medicare patients go unreported, and even when they are, hospitals rarely change the way they operate in order to prevent similar errors in the future, according to a new report from the Department of Health and Human Service's Office of the Inspector General (OIG).
The OIG found that hospital staff did not report 86% of adverse events, whether errors or accidents. Hospital administrators interviewed for the report suggested that doctors and nurses are unclear about what constitutes a reportable adverse event.
For their report, investigators selected 420 adverse events from an earlier OIG review on hospital errors and had physicians review the medical records on those cases.
The doctors identified 302 events of preventable harm to patients, 128 of which were considered serious, including a death from septic shock and four deaths from excessive bleeding after administration of anticoagulants.
To determine which of the 302 events were actually reported in hospital error-reporting systems, the OIG requested error reporting data from the hospitals where the selected adverse events occurred.
The OIG investigators also interviewed hospital administrators about the specific events and why they weren't reported. All of the hospitals involved had reporting systems in place and said they expected staff to report errors that resulted in patient harm, but none had a standardized list of which events should be reported.
The administrators told OIG investigators that the most common reasons that errors went unreported were that no clear error occurred leading up to the adverse event, that the event was thought to be a common side effect to the treatment, and that the event occurred so frequently that it was considered too common to report.
For instance, only one of 17 catheter-related infections -- a common event in Medicare beneficiaries -- was reported.
In his conclusion, report author Inspector General Daniel Levinson wrote that it is crucial that the adverse event reporting systems do what they're supposed to and said that the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) are in the best position to provide hospitals with guidance and incentives to better use reporting systems.
Specifically, AHRQ and CMS should create and promote an adverse event list to be used by hospitals, other healthcare providers, and medical and nursing schools. The list would detail the full range of patient harm that can occur in hospitals so hospital workers would have a clearer idea of what events should be reported.
CMS and AHRQ agreed with the recommendations, according to OIG.
Levinson also recommended that CMS provide guidance to accreditors on how to better assess hospital efforts to track and analyze adverse events. As a condition of participation in Medicare, hospitals must go through an accreditation process that proves they are tracking events that result in patients being harmed.
The OIG report on which the current analysis was based was done in 2010. It found that nearly 14% of hospitalized Medicare beneficiaries experienced a preventable adverse event that resulted in extended hospitalization, required life-sustaining intervention, caused permanent disability, or resulted in death.
An additional 13.5% experienced events that required some sort of additional treatment, but were not life-threatening, the 2010 report showed.
The idea of doing a better job of tracking patient harm as a result of medical treatment gained popularity after the Institute of Medicine's 1999 landmark report "To Err is Human: Building a Safer Health System." That report argued that hospitals can only address patient safety problems if adverse events are identified and adequately described.
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