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Hospitals Rarely Report Adverse Events, Says OIG

Cheryl Clark, for HealthLeaders Media, 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."

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1 comments on "Hospitals Rarely Report Adverse Events, Says OIG"


Dinesh Patel (7/23/2012 at 11:25 AM)
The culture of reporting to the DPH and Board of registration in medicine got started thru legislative mandate in Mass in 1987. Mass board of registration has unique systems in place as Patient care assessement regulations Such reporting to the Board has non punitive ,confidential , firewall built in with purpose being self education for contious improvement and there by improve safety well fare and quality and reduction of errors Worth for OIG and other states to look at what is happening in MASS state. good report and thanks Dinesh Patel MD