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

CMS is considering posting the incidence of hospital acquired conditions on its Hospital Compare Web site. It also may publish results of how findings of adverse events affect Medicare reimbursement, utilization, quality, patient safety, and any unintended consequences.

But, the OIG report said, "Although valuable for ascertaining the incidence of hospital-acquired conditions, Medicare claims data lack information about the causes of these conditions or prevention strategies, limiting their usefulness for improving patient safety."

The OIG also examined eight Patient Safety Organizations (PSOs), which are AHRQ-approved organizations that collect and analyze hospital data and may report back to hospitals with recommendations to improve patient safety and improve quality.

The PSOs reviewed included the California Hospital Patient Safety Organization, Clinical Practice Advancement Center, ECRI Institute PSO, HealthWatch, Human Performance Technology Group Inc., Institute for Safe Medication Practices, Missouri Center for Patient Safety, and Peminic Inc.