Hospitals' Adverse Event Reporting Systems Inadequate
Even though every hospital is required by its Medicare/Medicaid contract to have an internal adverse event reporting system—the existence of which is verified by accreditation agencies such as the Joint Commission—only 14% of adverse events experienced by beneficiaries were recognized as such internally, the OIG report said. Instead, they were seen as expected complications.
Classen advocates a federal system in which all hospitals are required to be transparent about all patient harm in a uniform way. And only when all those events are quantified and examined can the healthcare system prioritize which should be targeted first. Electronic health records, he says, can not only sound an alert when a potentially harmful event is about to occur, but retrospectively provide clues as to what led to it.
He notes that the septic shock death of Rory Staunton, the 12-year-old boy who died after he was mistakenly sent home from the emergency room of NYU Langone Medical Center with dangerously high levels of white blood cells and a fever, might have been prevented with such a warning system.
He adds that today, many hospital leaders are stuck in a mindset of thinking that very few harmful events are preventable. "The problem with deciding rigidly what is preventable and what is not is that over time, we've seen how preventability is a moving target," Classen explains.
For example, "We used to say that only one-third of hospital infections were preventable, but now, most people would agree that 75% to 80% are preventable. Ultimately, as we get smarter about this, we'll see that a lot more of it will be preventable, and even if we can't prevent it, it helps to identify it early and mitigate it."
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