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The OIG on incident reporting – beyond the headlines

By now, you’re probably aware of the HHS Office of Inspector General’s Jan. 6 report on hospital incident reporting. Its inflammatory title -- “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm” – was enough to ensure a fair amount of coverage in the consumer press, which has never exactly shied away from scary stories about the failure of hospitals to protect their patients.

The most widely reported statistic is that the incident reporting systems of the hospitals the OIG surveyed captured only 14% of the harm events experienced by Medicare beneficiaries. There’s no doubt that’s a striking number, and lay readers could be forgiven for coming away from some of the news coverage thinking hospitals are either neglecting their responsibilities or actively covering up incidents of patient harm. The problem is, there isn’t much in the actual report to support such cynical assumptions.

The catch for hospitals has always been that while they’re required to track medical errors and adverse patient events as a condition of participation in Medicare, “[f]ederal regulations do not specify means for meeting the requirements, nor do they explicitly define what ‘quality indicators’ or ‘adverse patient events’ hospitals should measure,” according to the OIG.

Further, as the OIG notes, “Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected.” As a result, many staff members simply aren’t sure what they’re supposed to report.

According to the OIG, for the 86% of events that staff didn’t report, 62% were “events that hospital staff most likely did not perceive as reportable.” About 12% weren’t reported because the harm event wasn’t caused by a perceptible error, “indicating that staff commonly equate the need to complete incident reports with medical errors.” Another 11% were because the harm was considered minor, and 9% because the event wasn’t on the hospital’s mandatory reporting list.

In light of all that, the OIG’s recommendations make a world of sense.

First, it says that CMS should work with the Agency for Healthcare Research and Quality to come up with and promote a comprehensive list of potentially reportable events. “That list,” the report says, “would educate hospital staff about the full range of patient harm that occurs in hospitals and would assist hospital administrators in assessing incident reporting systems.”

Second, it says that CMS should “provide guidance” to accreditors like The Joint Commission and DNV “regarding surveyor assessment of hospital efforts to track and analyze events and should scrutinize processes when approving accreditation programs.” In other words, expect your next survey to involve a closer look at your incident reporting system that focuses as much on how you collect data as what you do with it.

I would expect that most hospitals will welcome the creation of a standardized list blessed by both CMS and AHRQ. What remains to be seen is how much more onerous the reporting requirements will actually become.