OIG: Only 14% of patient harm events are reported
Despite federal regulations requiring hospitals participating in Medicare to develop and maintain Quality Assessment and Performance Improvement (QAPI) programs, hospital incident reporting systems only captured an estimated 14 percent of patient harm events experienced by Medicare beneficiaries discharged in October 2008, according to a January Office of Inspector General (OIG) report.
The findings were based on a survey of 189 hospitals of which 34 reported patient harm events. Out of the 86 percent of patient harm events that were not reported, respondents classified 61 percent as events that staff did not perceive as reportable and 25 percent as events that staff commonly report but did not report in that instance.
According to the survey’s results, reported events were not limited to benign events; hospital staff reported only two out of the 18 most serious events, or those resulting in permanent disability or death.
Additionally, survey results showed that nurses were the most likely members of hospitals’ staffs to report events, and that 28 of the 40 total reported events led to investigations and five led to policy changes.
The OIG’s report indicated that although hospital administrators seem enthusiastic about increasing patient safety and encourage their staff to report patient harm events, hospital administrators were also aware that their staff may have been unsure of when to report events and that their reporting systems were insufficient.
Because survey results showed that 89 percent of hospitals surveyed adhere to QAPI requirements and that hospitals rely heavily on incident reporting systems to identify problems, the OIG suggested that improving the effectiveness of those systems is critical to hospitals’ efforts to improve patient safety.
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) are in a position to assist hospitals in the development of more effective reporting systems, the OIG’s report suggested.
The OIG’s report recommended that the AHRQ and the CMS collaborate to create a list of potentially reportable events and to provide technical assistance to hospitals. It also recommended that CMS provide guidance to accreditors for assessing hospitals’ efforts to track and analyze events.
Upon receiving drafts of the OIG’s reports, both the AHRQ and the CMS responded agreeably to its recommendations. The CMS also stated that it has initiated collaboration, that it is developing draft guidance for surveyors regarding assessment of the QAPI within hospitals and developing a list of adverse events for informational purposes could be beneficial to improving incident reporting practices. The OIG's report is available in its entirety here.
The findings were based on a survey of 189 hospitals of which 34 reported patient harm events. Out of the 86 percent of patient harm events that were not reported, respondents classified 61 percent as events that staff did not perceive as reportable and 25 percent as events that staff commonly report but did not report in that instance.
According to the survey’s results, reported events were not limited to benign events; hospital staff reported only two out of the 18 most serious events, or those resulting in permanent disability or death.
Additionally, survey results showed that nurses were the most likely members of hospitals’ staffs to report events, and that 28 of the 40 total reported events led to investigations and five led to policy changes.
The OIG’s report indicated that although hospital administrators seem enthusiastic about increasing patient safety and encourage their staff to report patient harm events, hospital administrators were also aware that their staff may have been unsure of when to report events and that their reporting systems were insufficient.
Because survey results showed that 89 percent of hospitals surveyed adhere to QAPI requirements and that hospitals rely heavily on incident reporting systems to identify problems, the OIG suggested that improving the effectiveness of those systems is critical to hospitals’ efforts to improve patient safety.
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) are in a position to assist hospitals in the development of more effective reporting systems, the OIG’s report suggested.
The OIG’s report recommended that the AHRQ and the CMS collaborate to create a list of potentially reportable events and to provide technical assistance to hospitals. It also recommended that CMS provide guidance to accreditors for assessing hospitals’ efforts to track and analyze events.
Upon receiving drafts of the OIG’s reports, both the AHRQ and the CMS responded agreeably to its recommendations. The CMS also stated that it has initiated collaboration, that it is developing draft guidance for surveyors regarding assessment of the QAPI within hospitals and developing a list of adverse events for informational purposes could be beneficial to improving incident reporting practices. The OIG's report is available in its entirety here.