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Hospitals' Adverse Event Reporting Systems Inadequate

Cheryl Clark, for HealthLeaders Media, July 26, 2012

In other words, the systems by which the nation's hospitals detect and quantify patient harm within their facilities can be summarized with the Tower of Babel cliché:  It seems that everyone uses a different definition of what is a reportable adverse event.

David Classen, MD, an infectious disease expert at the University of Utah who developed the Institute for Healthcare Improvement's patient safety Global Trigger Tool and helped write the Institute of Medicine's report "Health IT and Patient Safety," agrees.


Validity of Tracking Questioned
"If you think you can go to your state and look at their adverse reporting events and have any clue what's going on in hospitals, you're smoking some very good stuff," Classen told me in an interview. "The first step is for us to admit that our whole system is tracking nothing valid."

His words may be harsh, but correct, even as they come after a November, 2010 OIG report that found that more than one in four Medicare beneficiaries endured hospital-caused harm. And for half of those, the harm was serious; some patients died. Nearly half of all these events, 44%, were preventable, the OIG said.

Variation in hospital adverse event reporting is a serious problem because it impedes our ability to learn if procedural changes and safeguards are working. But what's even worse is that none of these systems are actually capturing the bulk of adverse events that cause harm.

Even the very best state reporting systems, like Pennsylvania's, "only pick up a teeny, teeny fraction of all these adverse events," Classen says.   Instead, they are only picking up very serious events that are obvious, such as wrong-site surgery, or stolen newborns, or retained surgical objects. These are listed in the National Quality Forum's 28 "Serious Reportable Events."

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1 comments on "Hospitals' Adverse Event Reporting Systems Inadequate"


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.