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Hospitals' Adverse Event Reporting Systems Inadequate
An Office of Inspector General's report last week again poked holes in the credibility of the nation's hospital patient harm reporting system. After analyzing clinical records for Medicare beneficiaries treated by 189 hospitals, the agency determined those hospitals had reported only 1% of adverse events.
Four sentences of this report are of particular interest:
1. "To date, no Federal standards require States to operate adverse event reporting systems."
2. Half the states do not operate adverse event reporting systems to monitor the occurrence of harmful events in hospitals.
3. The 25 states and the District of Columbia that do have reporting standards "varied as to whether they made reporting voluntary or mandatory, what types of events they specified should be reported, and what additional information they asked hospitals to report."
4. "Hospital administrators indicated that staff often did not report events because they identified them not as patient harm, but rather as expected side effects."
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Comments are moderated. Please be patient.
Cynthia Jones, COHQ (7/26/2012 at 2:47 PM)
Regardless of a national standard and nomenclature - hospitals have the responsibility to First-do no harm. With that, humans make errors, and we are human. Health systems must facilitate a culture of safety to first - idenitfy, report and address actual harm with prevenatative strategies and system improvements. That is still a huge gap even in the "best centers". From that- organizations begin to learn to identify weaknesses in processes and do proactive strategies based on Near Misses... It's every healthcare members responsibility... It's about building and establishing fundamentals of safe care: Communication, Validation, and thorough assessment that utilze the bedside experts in care-who know processes and their variables - to build better care. It's not the Board, or The CEO, or The Managers, or The Staff. It's AND -all working for the same cause. It's culture. It's fundamental. It can be done.