The HHS Office of Inspector General recently reported that 13.5 percent of hospitalized Medicare beneficiaries experience adverse events during their hospital stays. This lack of reporting by incident reporting systems has resulted in prolonged hospitalizations, sometimes causing required life-sustaining interventions, has caused permanent disabilities, and has even resulted in death.
All of the hospitals reviewed for the report had incident reporting systems designed to capture events and their hospital administrators indicated that they rely heavily on the systems to identify problems. However, hospital accreditors report that they do not investigate event collection methods such as incident reporting systems unless evidence of a problem emerges through the survey process.
OIG recommends that AHRQ and CMS collaborate to create and promote a list of potentially reportable events for hospitals to use. They further recommend that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events.
The report "Hospital Incident Reporting Systems Do Not Capture Most Patient Harm" published January 2012 suggests that when hospitals collect information they use AHRQ’s Common Formats. Additionally, CMS should scrutinize survey standards when assessing hospitals and their compliance with the requirement to track and analyze events. They should also reinforce the assessment of incident reporting systems to improve event tracking.
OIG received comments on the draft report from AHRQ and CMS. AHRQ concurred with the recommendations and stated that they will collaborate with CMS to create a list of potentially reportable events and provide technical assistance to hospitals that use the list.
CMS also concurred with OIG’s recommendations stating that strengthening hospital reporting systems and practices is essential to preventing patient harm. Also, using a voluntary list of adverse events could be highly beneficial for improving incident reporting practices and that CMS is developing draft guidance for surveyors regarding assessment of patient safety improvement efforts within hospitals.
The full report is available at http://oig.hhs.gov/oei/reports/oei-06-09-00091.asp.
