Above is the headline of a USA Today story published on July 20, 2012. The article is based on a Memorandum Report issued by the Department of Health and Human Services, Office of the Inspector General, from Stuart Wright, the Deputy Inspector General for Evaluation and Inspections. The title of the memorandum report is, “Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.”
The memorandum report, and the USA Today article highlight the fact that hospitals seem to be ignoring state regulations that require them to report cases in which medical care harmed a patient. The USA Today article noted that this makes it almost impossible for health care providers to identify and fix preventable problems.
The Memorandum Report begins by stating that previous studies show that “…an estimated 27 percent of Medicare beneficiaries hospitalized in October 2008 experienced harm from medical care.” Many of these events were classified as serious adverse events, defined as events resulting in prolonged hospitalization, permanent disability, life-sustaining intervention, or death. Other events were classified as temporary harm events, defined as events requiring intervention but not resulting in lasting harm.
The report further stated that “…an estimated 60 percent of adverse and temporary harm events nationally occurred at hospitals in states with reporting systems, yet only an estimated 12 percent of events nationally met state requirements for reporting.” This meant that most events falling into this area did not get reported because they were not required to be reported.
Also alarming was the fact that hospitals often do not even recognize adverse events. The report stated, “We also found that hospitals reported only 1 percent of events. Most of the events that states required to be reported, but that hospitals did not report, were not identified by internal hospital incident reporting systems. This suggests that low reporting to state systems is more likely the result of hospital failure to identify events than from hospitals neglecting to report known events.”