Hospital workers reported only about 14 percent of the patient-safety incidents experienced by Medicare beneficiaries discharged in October 2008, according to a new report from the Office of the Inspector General (OIG).
Hospital staff failed to report the remaining 86 percent of patient harm events, partly due to staff misunderstanding what constitutes patient harm. Hospital administrators labeled 61 percent of the unreported events as those that staff did not identify as reportable and 25 percent as events that staff normally reported but did not report in this case, according to the OIG.
According to the report, all of the 189 hospitals reviewed used incident reporting systems to identify patient safety incidents. Although they rely heavily on such systems to track and analyze problems, administrators admitted they supply incomplete data about how often problems occur, the OIG notes.
To help hospitals ensure patient safety, the OIG recommends the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) join forces to enhance the efficiency of incident reporting systems.
AHRQ agreed that it will work with CMS to create a list of potentially reportable events, as well as offer technical assistance to help hospitals use the list, the report states. Similarly, CMS agreed to provide guidance to accreditors about their assessment of hospitals' patient safety improvement efforts.
In addition to incident reporting systems, hospitals could implement a program that encourages clinicians to report risky incidents before an adverse event happens. The "Good Catch Award" program at John Hopkins led to 27 potentially life-saving changes in only 24 months, according to a September 2011 article in Anesthesiology News.
For more information:
- read the OIG press release
- check out the OIG report (.pdf)