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Most hospital errors go unreported
1/11/2012
 
Most hospital errors that result in harm to Medicare patients go unreported, according to a recently released report from the Office of the Inspector General at the U.S. Department of Health and Human Services.

The OIG found that hospital staff did not report 86% of adverse events. Hospital administrators interviewed for the report suggested 61% of adverse events were not reported because hospital staff did not think they were reportable events. They did not have an explanation why the remaining 25% of adverse events were not reported.

The OIG also found that hospitals investigated only those incident reports which they considered were likely to lead to quality and safety improvements. However, they made “few policy or practice changes as a result of reported events,” the OIG reported.

All of the hospitals studied by the OIG had reporting systems in place, and said they expected staff to report errors that resulted in patient harm. None had a standardized list of events which should be reported.

Hospital administrators told OIG investigators adverse events went unreported for the following reasons: no clear error occurred leading up to the adverse event, the adverse event was thought to be a common side effect to the treatment, and/or the event occurred so frequently it was considered too common to report.

For instance, only one of 17 catheter-related infections – a common event in Medicare beneficiaries – was reported.