AHRQ: Rate of Adverse Events in Medicare Cases 'Disturbing'

John Commins, November 17, 2010

"While the report characterizes CMS as an oversight entity and the nation's largest health payer, CMS is also actively transitioning from serving solely as a regulator and passive payer of healthcare services to an agency that fully supports public health goals as an active payer of high quality and efficient care," Berwick said.

AHRQ Director Carolyn M. Clancy, MD, told Levinson she agreed with the findings, which she called "consistent with previous studies, but are nonetheless disturbing. They confirm that adverse events continue to affect hospital patients at an alarming rate and that the types of events that occur vary widely."

Clancy said the report "reaffirms AHRQ's need to continue to work on improving patient safety by broadening investigations to include areas that are not always seen on lists of adverse events that should never occur or should always be reported."

Clancy said AHRQ intends to foster continued improvement in both identifying and reducing adverse events through operational programs, research efforts, and further collaboration with other agencies.

The American Hospital Association issued these remarks Tuesday, "While hospitals have made great strides in improving care, this report highlights that there is more we can do. Hospitals are already engaged in important projects designed to improve patient care in many of the areas mentioned in the report. We are committed to taking additional needed steps to improve patient care. That is why we support the report's recommendations for further research to improve our understanding of what caused the error and how to prevent it from happening again.

The OIG report is based on a national sample of 780 Medicare beneficiaries discharged from acute care hospitals in October 2008. Physician reviewers used medical records to identify adverse events and assess whether each event was preventable. OIG used Medicare claims data to estimate Medicare costs.

John Commins

John Commins is a senior editor at HealthLeaders Media.

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