OIG: Adverse event reporting process varies regionally

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It is not appropriate to make a broad recommendation for a public disclosure process for adverse events in hospitals, according to a recent memorandum from the Office of Inspector General (OIG) at the Department of Health and Human Services (HHS).

“Entities collect adverse event data for different purposes, such as for generating information for patient safety improvements, conducting oversight of hospitals or processing payments for healthcare services,” stated Stuart Wright, deputy inspector general for evaluation and inspections at OIG.

Between July and September 2009, policies, practices and plans for publicly disclosing information about adverse event causes and prevention strategies while protecting patient privacy from 17 state adverse event reporting systems, eight patient safety organizations overseen by the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid (CMS) were reviewed.

The study found that seven state systems publicly disclosed more extensive information about the causes of adverse event and prevention strategies than other state systems. These state systems included Maryland, Massachusetts, New Jersey, Oregon, Colorado and Rhode Island. "This type of information, if disseminated by other state systems and entities that receive adverse event information, could help to improve patient safety," stated Wright.

Currently, the AHRQ is creating the Network of Patient Safety Databases (NPSD) to provide an evidence-based management resource for providers, patient safety organizations and other entities, according to OIG. The AHRQ plans to disclose adverse event information but the NPSD is not currently operational, the report stated.

CMS is limited in what it can disclose about hospital-acquired conditions, because claims data do not contain information about causes, concluded the report. “However, CMS’ plan to supplement claims data with other data sources appears to have the potential to generate new and useful information about hospital-acquired conditions, their causes and prevention,” Wright wrote.

All of the entities reviewed incorporate patient privacy protections, though they vary across entities and policies regarding what patient identifiers are collected and practices regarding disclosing patient identifiers and legal protections that apply to patient identifiers, the report found.

Noting a limitation to the study, OIG stated while “numerous entities collect information about adverse events, we could not examine all such entities for this memorandum report.”