Most Adverse Events in Hospitals Go Unreported

January 06, 2012

January 6, 2012 — Roughly 86% of patient mishaps in hospitals never make it into the databases of incident reporting systems designed to improve the quality of care, according to a study released today by the Office of Inspector General (OIG) in the US Department of Health and Human Services (HHS).

For 62% of adverse and "temporary harm" events not captured by these systems, staff did not believe they were reportable, said hospital administrators interviewed for the study.

Unreported incidents — some of which resulted in death — included hospital-acquired infections and 4 cases of excessive bleeding due to the administration of anticoagulants.

The OIG study recommends that the Centers for Medicare and Medicaid Services (CMS) collaborate with the federal Agency for Healthcare Research and Quality 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.

Right now, the 3 organizations that accredit hospitals — the Joint Commission, the American Osteopathic Association, and Det Norske Veritas Healthcare — do not have standardized lists of reportable patient incidents.

No Hospital Had List of Reportable Events

The OIG study builds upon a previous one published in 2010 that painted a discouraging picture of care gone awry in hospitals. The 2010 study found that 13.5% of hospitalized Medicare patients experience adverse events ranging from pulmonary embolisms to wrong-body-part surgery. Another 13.5% experience temporary-harm events, such as excessive bleeding and prolonged nausea.

The OIG extrapolated those numbers from an analysis of 780 Medicare patients with a combined 838 hospital stays with discharges in October 2008. The most recent study focused on 174 temporary-harm events and 128 adverse events in this patient sample for a grand total of 302 events. The adverse events selected met at least 1 of 3 criteria. They had to appear on the list of Serious Reportable Events compiled by the National Quality Forum or 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 the like. 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.

"However, none of the hospitals maintained a list of events required to be reported," the report stated.

Forty (14%) of the 189 adverse and temporary-harm events were captured by the incident reporting systems at 34 hospitals. The other 86% fell through the cracks.

For most of the unreported events (62%), hospital staff probably did not consider them reportable, according to administrators. Of the reasons given, these 4 topped the list:

  • The event was not caused by a perceptible error. This reason, according to the OIG, indicated that "staff commonly equates the need to complete incident reports with medical errors."

  • The event was an expected outcome or adverse effect.

  • The harm involved was minor, ameliorated, or both.

  • 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.

Nurses Did Most Incident Reporting

Incident-reporting systems usually are designed so any member of a hospital staff can use then, according to the OIG. However, of the 40 adverse and temporary-harm events that were reported in the study, 31 were brought to light by nurses.

Nurses discovered 24 events, for example, by observing patients under their care. They also played a part in routine hospital safety assessments that uncovered 7 more events.


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