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Hospitals Rarely Report Adverse Events, Says OIG

 |  By cclark@healthleadersmedia.com  
   July 23, 2012

Hospitals rarely inform state health departments about adverse events that cause temporary or serious harm to patients, often because states don't require that they be reported, but also because treatment teams don't identify such events, according to an Office of Inspector General "Memorandum Report" issued Thursday.

"Hospital administrators indicated that staff often did not report events because they identified them not as patient harm, but rather as expected side-effects," the report said. Most of the events were not even captured by the hospital's internal reporting system, even though each of the 189 hospitals that had one of the events had such an incident reporting system.

Yet many of the events that hospitals failed to report to states as the states required involved serious harm to Medicare beneficiaries and six contributed to patient death "including cases involving lack of patient monitoring and missed diagnoses. 

For example one patient death was the result of acute renal failure caused by the hospital not recognizing and treating a serious systemic inflammatory response syndrome (bacteremia).  "Another patient death was the result of poor insulin management escalating to a hypoglycemic coma," the report said.

The OIG report noted, "To date, no Federal standards require States to operate adverse event reporting systems."

The OIG sent teams of experts to review medical records of 780 Medicare beneficiaries hospitalized in during the month of October, 2008.  

They found that 60% of adverse and temporary events nationally occurred at hospitals in states with reporting systems. But only 12% of the events met state requirements for reporting. Additionally, hospitals reported only 1% of the events.

The report, sent to Acting Administrator for the Centers for Medicare & Medicaid Services Marilyn Tavenner, follows a series of reports on the occurrence of adverse events, hospitals' recognition of those events, and the reporting of them. 

Recently, the OIG said that it found that about 27% of Medicare beneficiaries who were hospitalized in October of 2008 experienced harm from medical care. About half of those involved "prolonged hospitalization, permanent disability, life-sustaining intervention or death," while another half involved temporary harm, in which an intervention was required, but for which the harm did not last.

The OIG report points to a spotty system around the country for identifying and reporting events that cause harm.  Only 26 states including the District of Columbia have reporting requirements, but only 23 of those 26 regularly investigate those events.

Of all the events analyzed, only 60% occurred in states with event reporting systems.

Additionally, eight of the 26 states do not use the event reports to provide patient safety information and educational tools to hospitals or prepare analyses of contributing factors or widespread threats to patient safety that could prevent those incidents from being repeated elsewhere.

The OIG report is the latest in a series of federal reports about adverse events in hospitals.

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