A troubling number of medical errors slip through the cracks at hospitals, and facilities don’t often change hospital policies when errors are detected, according to a new report released Jan. 5 by the Office of the Inspector General at the U.S. Department of Health and Human Services.
The investigation found that 86 percent of medical errors among Medicare beneficiaries at hospitals are not caught by facilities’ incident reporting systems. In other words, only about 14 percent of harm incidents that Medicare patients experience are actually discovered by hospitals.
The study was based on an independent review of patient records at 189 hospitals. Investigators collected incident reports from hospitals where these adverse and temporary harm events occurred and interviewed administrators from hospitals.
All of the hospitals included in the study had incident reporting systems designed to capture medical errors, and administrators from hospitals with reported errors – 34 hospitals – indicated that they “rely heavily” on these systems to identify problems and make patient safety improvements.
In the report, the administrators acknowledged that incident reporting systems provide incomplete information about how often medical errors occur, but they continue to rely on these systems primarily because they value staff accounts of these incidents.
Nurses reported adverse events most often and usually identified reportable events through the regular course of care and also by completing hospital safety assessments designed to identify errors.
Out of the 40 reported events, 28 of them led to investigations and five led to policy changes.
Hospitals only looked into 14 percent of medical errors – those that they considered most likely to lead to quality and safety improvements. Out of the remaining adverse events, 61 percent of hospitals did not think the events were reportable and 25 percent were events that hospital staff commonly report but did not report this incidents reviewed in the study.
In a 2010 report, the OIG found that 13.5 percent 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. An additional 13.5 percent experienced temporary harm events that required treatment.
In that study, an estimated 15,000 Medicare patients experienced medical errors in the hospital that contributed to their deaths each month. The OIG calculated that Medicare patients harmed during that month required an additional $324 million in hospital care. The study estimated the annual cost for these events in hospital care alone is $4.4 billion.
The Consumers Union, a nonprofit organization that produces Consumer Reports, said hospitals should not only do a better job at reporting medical errors but that the information should be made available to the public.
"One in four hospital patients are harmed by medical errors and infections, which translates to about 9 million people each year," Lisa McGiffert, director of the Consumers Union's Safe Patient Project, said in a statement. “Too many hospitals are doing a poor job of tracking preventable infections and medical errors and making the changes necessary to keep patients safe.”
In order to participate in the federal Medicare program, hospitals are required to develop and maintain a Quality Assessment and Performance Improvement, or QAPI, program. To satisfy QAPI requirements, hospitals must track medical errors and adverse patient events, analyze their causes and take step to prevent these incidents from occurring. The Agency for Healthcare Research and Quality (AHRQ) has a standardized set of event definitions and incident reporting tools known as the Common Formats that hospitals follow.
In response to the report, the AHRQ and the Centers for Medicare and Medicaid will collaborate to create and promote a list of medical errors that hospitals will track and report to the agency. In turn, the OIG will provide technical assistance to hospitals on how to use the new reporting list.
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