Back in Novenber of 2010 we wrote in this blog of a report issued by The Office of Inspector General for the Department of Health and Human Services regarding statistics from a study indicating that an estimated one in seven elderly patients experience some sort of medical error or other adverse effect from their hospitalization. Earlier this month the Office of Inspector General released a new report indicating that the hospital incident reporting systems do not capture most patient harm that occurs in hospitals.
In the 2010 report, the department of Health and Human Services found that 13.5 % of hospitalized Medicare beneficiaries experienced adverse events during their hospital stays that resulted in prolonged hospitalization, required life-sustaining intervention, caused permanent disability, or resulted in death. Additionally, 13.5 % experienced temporary harm events that required treatment. The recently released report collected incident reports from hospitals where these adverse and temporary harm events occurred and interviewed administrators from hospitals and representatives of accreditors.
The study found: Hospital staff did not report 86 % of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm. Nurses most often reported events, typically identified through the regular course of care. Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected.
The study was based on an independent review of patient records at 189 hospitals. Forty events were reported, twenty eight of which led to investigations and five led to policy changes. Hospitals only looked into the 14 percent of medical errors which they considered most likely to lead to quality and safety improvements. Of the remaining 86 percent, roughly 62% of hospitals did not consider the events reportable and roughly 25% were events that hospital staff typically report but did not report during the study.