Hospitals fail to report serious adverse events to accrediting bodies, according to a Tuesday report by the Inspector General, reports USA Today. With hundreds of hospital errors unreported, Medicare inspectors should better track serious hospital mistakes and the effectiveness of hospital policy changes following mistakes, according to Inspector General Daniel Levinson.
An estimated 13.5 percent of hospitalized Medicare beneficiaries experienced some type of adverse event in a month, according to the Springfield News-Leader. The report found that regional offices of the Centers for Medicare & Medicaid Services (CMS) alerted accreditors in only 28 of the 88 immediate jeopardy complaints, that is, the never events related to surgical fires, patient suicides, sexual assault, wrong-patient surgeries, and medical instruments left inside a patient after a surgery, according to USA Today.
What's more is that state agencies only required one out of 19 hospitals to submit performance data after requiring corrective action plans.
On par with the transparency movement, the Patient Safety and Quality Improvement Act in 2005 allowed hospitals to report errors to patient safety organizations but through confidential reports. The confidentiality approach is aimed at encouraging hospital staff to report problems, as well as protecting hospitals from possible litigation.
However, patient advocates argue that the secrecy can harm patients.
"Basically, they're swept under a rug," said D.K. Raymer, founder of patient advocacy organization HealthCare PSI in Illinois in the Springfield News-Leader article.
For example, two-thirds of Missouri hospitals haven't reported adverse events to the Missouri Center for Patient Safety, according to the article.
It's unclear whether the problem stems from oversight issues or unclear instructions from CMS, notes USA Today.
Inspector General Levinson recommended that CMS implement quality measurements to ensure compliance, clearly tell hospitals what mistakes they've made, and notify accreditors of hospitals' errors. The Inspector General also recommended that state agencies monitor hospitals' improvements.
For more information:
- read the USA Today article
- read the Springfield News-Leader article
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