The OIG report points to a spotty system around the country for identifying and reporting events that cause harm. Only 26 states including the District of Columbia have reporting requirements, but only 23 of those 26 regularly investigate those events.
Of all the events analyzed, only 60% occurred in states with event reporting systems.
Additionally, eight of the 26 states do not use the event reports to provide patient safety information and educational tools to hospitals or prepare analyses of contributing factors or widespread threats to patient safety that could prevent those incidents from being repeated elsewhere.
The OIG report is the latest in a series of federal reports about adverse events in hospitals.