Most hospital errors unreported, HHS says
Hospital incident reporting systems captured only an estimated 14% of the patient harm events experienced by Medicare beneficiaries, according to a new report by the Department of Health and Human Services (HHS).
Hospitals investigated those reported events that they considered most likely to lead to quality and safety improvements and made few policy or practice changes as a result of reported events, according to the report "Hospital Incident Reporting Systems Do Not Capture Most Patient Harm." (The report is available online at http://tinyurl.com/7np8gvu.)
Hospital administrators classified the remaining events (86%) as events that staff did not perceive as reportable (61%) or as events that staff commonly report but did not report in this case (25%). (For more findings in the report, see the story at right.)
The report notes that as a condition of participation in the Medicare program, federal regulations require that hospitals develop and maintain a Quality Assessment and Performance Improvement (QAPI) program. To satisfy QAPI requirements, hospitals must "track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital." To standardize hospital event reporting, the Agency for Healthcare Research and Quality (AHRQ) developed event definitions and incident reporting tools known as the common formats.
For the report, HHS requested and reviewed incident reports from hospitals regarding patient harm events. All of the hospitals reviewed had incident reporting systems designed to capture events. Hospital administrators interviewed indicated that they rely heavily on the systems to identify problems. Hospital accreditors reported that they do not investigate event collection methods, such as incident reporting systems, unless evidence of a problem emerges through the survey process.
"Because hospitals rely on incident reporting systems to track and analyze events, improving the usefulness of these systems is critical to hospitals' efforts to improve patient safety," the report says. "Therefore, we recommend that AHRQ and the Centers for Medicare and Medicaid Services [CMS] collaborate to create and promote a list of potentially reportable events for hospitals to use. We further recommend that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events."
HHS also says CMS should suggest that surveyors evaluate the information collected by hospitals using AHRQ's common formats. Additionally, CMS should scrutinize survey standards for assessing hospital compliance with the requirement to track and analyze events and reinforce assessment of incident reporting systems as a key tool to improve event tracking, the report says.
Hospital incident reporting systems captured only an estimated 14% of the patient harm events experienced by Medicare beneficiaries, according to a new report by the Department of Health and Human Services (HHS).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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