GAO: Pressure on occ health to underreport

Report urges changes to improve injury logs

One-third of occupational health practitioners have faced pressure from employers or workers to undertreat and underreport work-related injuries, according to a report by the U.S. Government Accountability Office (GAO), an investigative arm of Congress.

Such pressures, as well as other weaknesses in worksite record keeping and the audits of employer records, have led to an undercount of the nation's work-related injuries, the GAO concluded.

The U.S. Occupational Safety and Health Administration responded that it "welcomes" the report and will adopt the GAO recommendations, which include having OSHA inspectors interview workers about work-related injuries and illnesses.

"Many of the problems identified in the report are quite alarming, and OSHA will be taking strong enforcement action where we find underreporting," Secretary of Labor Hilda L. Solis said in a statement.

The Department of Labor has long been criticized for failing to adequately track workplace injuries and illnesses, either through OSHA logs or the Bureau of Labor Statistics. Each year, the Labor Secretary (whomever was in office) has touted a decline in the injury rate as evidence of safer workplaces.

But in an analysis based on other data sources of occupational injuries, Lee Friedman, PhD, research assistant professor at the University of Illinois at Chicago (UIC) School of Public Health, and his colleague Linda Forst, MD, MPH, MOS, a professor of environmental and occupational health at UIC, estimated that injuries in high-risk industries have declined in total by about 4% since 1992.1

Friedman called the anticipated changes, based on the GAO recommendations, "a good beginning."

"They made several points that I'm glad they addressed," he says. "The key one is the overreliance on employer reporting and the need to interview employees."

Timely interviews of workers

OSHA already had heightened its focus on record-keeping compliance through its National Emphasis Program, which targets workplaces in high-risk industries that report low injury rates. The GAO recommendations call for OSHA inspectors to interview workers during records audits.

If workers that were initially selected are not available, the OSHA inspectors are to substitute other workers. The GAO also advised OSHA to shorten the time between the date injuries and illnesses are recorded by employers and the date they are audited, to make the audits more useful.

When OSHA fails to interview workers during a record-keeping audit, they "may miss opportunities to obtain information from workers about injuries and illnesses that may not have been properly recorded by employers on their injury and illness logs," the GAO said.

Meanwhile, a lag time of about two years between the audit and the injury or illness reporting makes it difficult to learn about underreporting, the GAO said. "Because of this lag, inspectors told us many workers are no longer employed at the worksite and those who remain may be unable to remember the injury or illness," the GAO said.

Yet the GAO stopped short of recommending fundamental changes in the way OSHA tracks the nation's workplace injuries and illnesses. In research in Michigan, Kenneth D. Rosenman, MD, chief of the Division of Occupational and Environmental Medicine at Michigan State University in East Lansing, found that the reporting system missed about two-thirds of injuries and illnesses. To be more accurate, surveillance needs to include other data sources, such as hospital emergency departments, he says.

The GAO recommendations are "directed at improving the existing employer-based system," says Rosenman. "Certainly, that needs to be improved. I like the current recommendations and I'm glad OSHA is going to adopt them, but there's still going to be lots of underreporting."

One troubling finding: Occupational health practitioners reported pressure by both employers and workers to understate or undertreat work-related injuries. Rosenman noted that this highlights the flaws in a reporting system based entirely on employer and worker reports.

According to the GAO: "One practitioner said that an injured worker's manager took the worker to multiple providers until the manager found one who would certify that treatment of the injury required only first aid, which is not a recordable injury. Fifty-three percent of the health practitioners reported that they experienced pressure from company officials to downplay injuries or illnesses, and 47% reported that they experienced this pressure from workers. Further, 44% of health practitioners stated that this pressure had at least a minor impact on whether injuries and illnesses were accurately recorded, and 15% reported it had a major impact."

"To me, it speaks to the insufficiency or danger of an employer-based system where the person doing the counting has incentive ... to minimize that number," he says.

Rosenman notes that the National Institute for Occupational Safety and Health is developing a supplement to the National Health Interview Survey that will address occupational injury and illness. However, it's not clear how often that supplement would be used. It would need to be repeated on a regular basis to be useful in surveillance, Rosenman says.

OSHA will assist employers

Few worksites are likely to undergo an audit related to record keeping. While nursing homes are among the high-risk industries covered by the National Emphasis Program, hospitals are not.

But employers are likely to see greater resources available to comply with record-keeping rules. The GAO recommended additional assistance to employers.

Misunderstandings result in a miscount, the GAO said: "[S]ome individuals charged with maintaining employers' OSHA logs erroneously think that the criteria for recording injuries and illnesses are the same as the eligibility criteria for filing workers' compensation claims. Therefore, they may be less likely to record injuries and illnesses that are not compensable through the workers' compensation system."

That additional assistance is needed, says Friedman. "I think everybody across the board could use training," he says. "It is complicated."


1. Friedman LS, Forst L. The impact of OSHA recordkeeping regulation changes on occupational injury and illness trends in the U.S.: A time series analysis. Occup Environ Med 2007; 64:454-460.