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Hospitals' Adverse Event Reporting Systems Inadequate

Cheryl Clark, for HealthLeaders Media, July 26, 2012

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."

But, Classen explains, those 28 "are rare, orders-of-magnitude less-common than other adverse events that occur in hospitals, such as side effects of drugs, or complications from procedures or infections. That's where the money is. But unfortunately, these reporting systems don't address those."

To date, hospital reporting systems don't routinely pick up, for example, harmful urinary tract infections that can lead to sepsis and patient death, especially in a patient who is frail.

Adverse Event or 'Expected Complication'?

Classen explains: "the hospital administrator will say, 'Oh, that's not an adverse event; that's an expected complication.' Well, my comment back is, 'No. If you had used the catheter properly, you could have gotten it out quickly and this wouldn't have happened.' "

Apparently, many hospitals today just put these events into the category of "Sometimes Bad Stuff Just Happens,"or chalk it up to the natural deterioration of the patient's condition. There's no event report, internal or external.

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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.