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."