February 4, 2012

"TO ERR IS HUMAN" - Hospital Errors Which Harm

Hospital staff still fail to report most patient harm

Thirteen years after the Institute of Medicine took health care providers to task in its seminal report To Err is Human for underreporting medical errors, hospital personnel still do not report most incidents in which patients are harmed as a result of medical care. This was the finding of a new U.S. Department of Health and Human Services Office of the Inspector General (OIG) investigation.

The investigation looked at 189 hospitals where Medicare patients discharged in October 2008 experienced 293 unique adverse events, such as medication errors, surgery errors, falls, and hospital-acquired infections. Federal investigators found that hospital staff failed to report the events 86 percent of the time, despite internal incident reporting systems meant to improve patient safety by preventing recurrences.

The OIG report comes after a study last year which found that methods commonly used to detect adverse events in U.S. hospitals missed 90 percent of the events. In that study of three hospitals, just 1 percent of adverse events were captured by the hospitals' voluntary reporting systems.

Hospital administrators admitted that "underreporting can affect patient safety efforts by potentially skewing resources toward prevention of more easily identifiable occurrences that happen at a point in time (such as patient falls) rather than complex events that occur over a longer period and are more difficult to detect (such as blood clots)," the OIG report said.

However, hospital administrators told investigators that staff often may be confused about what constitutes harm and what needs to be reported.

Hospitals must track adverse patient events as a condition of their participation in the Medicare program, and the vast majority of U.S. hospitals do. However, federal regulations and accrediting agencies' requirements are silent as to how hospitals should identify and analyze the events; it is left to individual hospitals to determine which adverse events to monitor. Investigators found that among a subsample of 34 hospitals, none maintained a list of events that staff are required to report.

The hospital administrators interviewed for the OIG report said personnel likely did not perceive 62 percent of the unreported events as reportable, while 25 percent of the unreported events were those that staff would normally report but didn't.