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CMS Pushed to Improve Reporting on Adverse Events

Cheryl Clark, for HealthLeaders Media, November 2, 2011

A new Office of Inspector General report criticizes the Centers for Medicare & Medicaid Services for failing to notify accreditation agencies, such as the Joint Commission, in two out of three sampled cases involving serious adverse events in hospitals. These include immediate jeopardies such as medication and surgical errors, physical abuse by hospital staff, and patient suicide.

"CMS regional offices notified accreditors of only 28 of the 88 sampled complaints against accredited hospitals," the report says.

In an interview with HealthLeaders Media, Patricia Kurtz, director of federal relations for the Joint Commission, which accredits most of the nation's hospitals, said the agency was pleased at the OIG's findings and had been concerned about the lack of notification from CMS.

"We want to know about these because it gives us the overarching picture of performance of the entities we're accrediting. And we use these on the next survey," she says.

Kurtz says that in her seven years at the organization, the commission "has asked many times for CMS to send us this information on a timely basis." While about three of the 10 regional offices have been reliable, she says, the others have been less so. "some we don't hear from on a timely basis. I wouldn’t say we’re ignored, rather it is probably not high on their list of priorities."

However, the OIG report notes that CMS' policy explicitly state the obligation to notify accreditation agencies in the event of serious adverse events that could affect accreditation status.

Additionally, the OIG found that CMS and the state agencies that conduct investigations on CMS' behalf have "missed numerous other opportunities to incorporate patient safety principles" such as requiring longer term monitoring.

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