Hospitals treating a sample group of 780 Medicare patients in October 2008 severely underreported adverse events, despite the fact that the states in which the problems occurred require rigorous reporting. So said Health and Human Services’ Office of Inspector General (OIG) in a report released July 19.
The report stated that the OIG found an estimated 60 percent of adverse and “temporary harm” events occurred at hospitals in states with reporting systems, yet only 12 percent or so met state requirements for reporting.
More troubling still, the hospitals under review reported only 1 percent of events.
The report noted that most of the unreported events went undetected by internal hospital incident reporting systems, suggesting that the low reporting owes not to willful negligence but to “hospital staff not identifying incidents of harm as reportable events.”
Many of the unreported events involved serious harm. Six of 32 such situations contributed to patient death, and lapses included lack of patient monitoring, missed diagnoses and other easily preventable blunders. In one case, a patient died after poor insulin management escalated to a hypoglycemic coma.
“The less serious, temporary harm events that hospitals did not report included many events that can become serious if not ameliorated, such as excessive bleeding and intravenous volume overload,” read the report. “The treatment required to stop the progression of these events also implies that in each case, hospital staff were likely aware of the patient’s condition but did not perceive the condition as an event.”
The OIG report follows a February study by HHS’ Agency for Healthcare Research and Quality (AHRQ) that suggested hospital culture may play a substantial role in the widespread underreporting of adverse events. After surveying 567,703 staffers at 1,128 hospitals, AHRQ reported that more than half of respondents (54 percent) said adverse-event reporting “feels like the person is being written up, not the problem,” while just under half said they worried their employers held their mistakes against them in some way.
The new OIG report, which was prepared as a memo from an OIG official to the acting administrator of the Centers for Medicare & Medicaid Services, is available as a downloadable PDF .