HHS IG Issues Sobering Report on Errors

Hospital staffs did not report 87 percent of errors, although they were required to, according to the inspector general's report.

Roughly 27 percent of Medicare beneficiaries are harmed in some way while hospitalized, according to a July 20 report from the inspector general of the U.S. Department of Health and Human Services. About 44 percent of those harmful episodes were preventable, as well.

The IG undertook the analysis of adverse events because of the Tax Relief and Health Care Act of 2006, not the passage or signing of the Affordable Care Act. The analysis concluded the cost to Medicare from adverse events amounts to an estimated $324 million per month, or $4.4 billion annually.

The most significant findings in the report involve Medicare-participating hospitals' reporting of adverse events. While they are required to report them, the IG staff found 86 percent of events were not reported to incident reporting systems.

"Previous explanations for low reporting levels include the following: (1) staff do not have time, (2) staff fear punitive action, and (3) staff do not believe that reports will lead to improvement. However, this report found that the low level of reporting is also due partly to hospital staffs' lack of understanding as to what constitutes patient harm. Therefore, OIG recommended that AHRQ and CMS develop a list of potentially reportable events to assist hospital staff," the IG office stated.

Also, there is no comprehensive national reporting system for adverse events. Only half of the states have them, and their systems vary widely, according to the report. The IG's office said it will continue to examine adverse events, including looking beyond hospitals to other medical settings, and is already working on a study of adverse events in nursing homes. Visit http://oig.hhs.gov/newsroom/spotlight/2012/adverse.asp for more information.

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