Most Errors at Hospitals Go Unreported

The report, issued by the Office of Inspector General (OIG) in the US Department of Health and Human Services (HHS; Washington DC, USA) analyzed the records of 780 Medicare patients with a combined 838 hospital stays with discharges in October 2008. The researchers focused on 174 temporary-harm events and 128 adverse events in this patient sample, for a grand total of 302 events. The adverse events had to meet least 1 of 3 criteria; they had to appear on the list of serious reportable events compiled by the US National Quality Forum, or on the list of hospital-acquired "never" conditions no longer reimbursed by Medicare, or else result in a prolonged hospital stay, permanent harm, life-sustaining interventions, or death.

The OIG then requested incident reports from the 195 hospitals associated with the 302 events and received responses from 189 hospitals on 293 events. All 189 hospitals operated incident-reporting systems in addition to specialized ones for tracking infections, pharmacy errors, and etcetera. Hospital administrators interviewed for the study said that employees were instructed to report instances of patient harm, and that they typically received training on how to report specific types of problems. In all, only 40 (14%) of the 189 adverse and temporary-harm events were captured by the incident reporting systems at 34 hospitals; the other 86% went unreported. For most of these unreported events (62%), hospital staff probably did not consider them reportable, according to hospital administrators.

Some of the reasons given for the lapse in reporting were that the event was not caused by a perceptible error; that the event was an expected outcome or adverse effect; that the harm involved was minor, ameliorated, or both; or that the event was not on the hospital's mandatory reporting list. The rest of the unreported events, or roughly 25% of the total, were ones that hospital staff commonly reported but in these instances did not. Administrators said that limited time and the assumption that somebody else would report the event could be the reasons.

“Despite the existence of incident reporting systems, hospital staff did not report most events that harmed Medicare beneficiaries,” said Inspector General Daniel Levinson. “Some of the most serious problems, including some that caused patients to die, were not reported.”

The OIG study therefore recommends that the Centers for Medicare and Medicaid Services (CMS; Baltimore, MD, USA) collaborate with the US federal Agency for Healthcare Research and Quality (AHRQ; Rockville, MD, USA) to develop a master list of potentially reportable events that hospitals and other healthcare providers can use to eliminate any confusion or uncertainty about what constitutes patient harm. In addition, CMS should provide guidance to organizations that survey or accredit hospitals on assessing incident reporting systems and the use of the master list.

Related Links:
US Department of Health and Human Services
Centers for Medicare and Medicaid Services
Agency for Healthcare Research and Quality