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States Not Reporting Adverse Events May Harm Patient Safety, Says Inspector General

Cheryl Clark, for HealthLeaders Media, January 8, 2010

Public reporting of adverse events occurring in hospital settings—a strategy seen as a way to improve safety—is limited and inconsistent state by state, according to a memorandum issued this week by the Office of Inspector General.

Seven state systems disclose more information than others and may serve as models, but three states have less extensive disclosure systems and seven systems have no public disclosure, the report said. Only 17 systems were reviewed.

The seven disclosing more information include Maryland, Massachusetts (two systems), Minnesota, New Jersey, Oregon, and Pennsylvania. The three that disclose less are Colorado, Maine, and Rhode Island, and the seven states with no public disclosure are Utah, Florida, Nevada, New York, South Carolina, South Dakota, and Vermont.

Furthermore, there is no centralized reporting system to which all facilities can submit data to or access to review in order to learn solutions to avoid repeating those events, wrote Stuart Wright, deputy inspector general for evaluation and inspections, who signed the report.

"Rather, there are separate federal, state, and nongovernmental entities that receive and disclose adverse event information," he wrote. "Depending on the entity, reporting is either voluntary or mandatory, and the entities have different data collection procedures, privacy protections, and dissemination practices."

"Such disclosure may provide the medical community with valuable information for improving patient safety," Wright wrote.

The OIG memorandum, entitled "Adverse Events in Hospitals: Public Disclosure of Information About Events," was mandated by the Tax Relief and Health Care Act of 2006, because the OIG is supposed to recommend potential processes for public disclosure of information about events in a way that ensures public privacy.

The memorandum contained no recommendations, but was addressed to Charlene Frizzera, acting administrator of the Centers for Medicare and Medicaid Services (CMS), and Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ).

Collecting and disseminating such information in a way that identifies common errors in providing healthcare as well as remedies has been a long-time goal. AHRQ plans to disclose adverse event information in a Network of Patient Safety Databases that it is creating and will maintain.

Additionally, CMS doesn’t pay for additional care that resulted from 10 different adverse events: the unintended retention of a foreign object in a patient after surgery, air embolism, pressure ulcers, falls, catheter-associated urinary tract infections, blood incompatibility, poor glycemic control, vascular catheter associated infections, deep vein thrombosis or pulmonary embolism associated with hip or knee replacement, and surgical site infection.

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