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OIG: Only one in seven hospital errors is reported

Hospitals rarely change practices to prevent recurrences

Topics: Safety, Quality, Performance Improvement, Outcomes, Never Event, Medical Errors

January 06, 2012

Hospital employees report just one out of every seven medical errors, mishaps, and other preventable events involving Medicare patients, according to a new HHS Office of the Inspector General report.

Such events include medication errors, overuse of painkillers and other drugs, hospital-acquired infections and severe bedsores, the study found.

HHS Inspector General Daniel Levinson said hospitals receiving Medicare reimbursement are required to "track medical errors and adverse patient events, analyze their causes" and improve care. However, the federal investigation—which included comprehensive reviews of 293 cases where patients experienced adverse events—found that many hospital workers are not aware of "what constitutes patient harm" or realize that particular events that harmed patients should have been reported, he noted.

According to Levinson, workers in many cases either assumed that someone else would report the problem, thought the events were so common that they did not need to be reported, or "suspected that the events were isolated incidents unlikely to recur." He added that some of the most serious problems that resulted in patient deaths were not reported. He estimated that more than 130,000 Medicare beneficiaries experienced some type of adverse event in hospitals in a single month.

Meanwhile, the investigation—which involved independent physicians who reviewed patients' records—found that when workers reported the events, hospitals rarely changed their policies or practices to prevent recurrences. Of the 40 cases that were reported to hospital managers, 28 were investigated and just five led to changes in policies or practices.

Medicare officials said they plan to establish a list of "reportable events" that hospitals and their workers must consult. In addition, hospitals will be directed to provide workers with "detailed, unambiguous instructions on the type of events that should be reported," according to CMS (Pear, New York Times, 1/6).

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