Few adverse events reported to state systems

Many adverse events in hospitals are never reported to state adverse event reporting systems, according to a recent report by the Department of Health and Human Services Office of Inspector General (HHS OIG).

Previous OIG work found that an estimated 27% of Medicare beneficiaries hospitalized in October 2008 experienced harm from medical care, either serious adverse events (defined as events resulting in prolonged hospitalization, permanent disability, life-sustaining intervention, or death) or temporary harm events (defined as events requiring intervention but not resulting in lasting harm).

To determine this rate of adverse and temporary harm events (referred to collectively as events), OIG investigators examined medical records for a nationally representative sample of 780 hospitalized Medicare beneficiaries in October 2008. Prior OIG work also found that in 2008, about half of states operated adverse event reporting systems to monitor the occurrence of events in hospitals.

Typically, these states required hospitals to report only specific types of events and analyzed the events in aggregate. The investigators found that an estimated 60% of adverse and temporary harm events nationally occurred at hospitals in states with reporting systems, yet only an estimated 12% of events nationally met state requirements for reporting.

“We also found that hospitals reported only 1% of events. Most of the events that states required to be reported but that hospitals did not report were not identified by internal hospital incident reporting systems,” they wrote. “This suggests that low reporting to state systems is more likely the result of hospital failure to identify events than of hospitals’ neglecting to report known events.”

The full report is available online at http://tinyurl.com/cu6voo2.