Many hospital errors that harm Medicare patients are never reported, and thus can never be tracked or corrected, according to a report from federal investigators released Friday.
“Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm,” the Office of Inspector General of the Health and Human Services Department wrote in its report.
“Of the events experienced by Medicare beneficiaries discharged in October 2008, hospital incident reporting systems captured only an estimated 14 percent.”
Harmful mistakes that were never reported included hospital-acquired infections, delirium resulting from overuse of painkillers, severe bedsores and excessive bleeding, according to the report.
Even when hospitals do investigate reported mistakes, they rarely change their policies to make sure that such errors never happen again, the report found. Investigators also conducted an in-depth review of 293 cases of harm and found that 40 were reported to hospital managers, 28 were investigated, and five led to a change in hospital policy.
The results built off a November 2010 report, by the same agency, that found that 27 percent of hospitalized Medicare patients had at least one ‘adverse event’ or suffered a temporary harm while receiving hospital care.
To receive payment under Medicare, hospitals are required to track errors and harm done to patients, to figure out why mistakes occurred and improve care accordingly.
“Today’s report confirms what many other studies have already documented. Hospitals are doing a poor job of tracking preventable infections and medical errors and making the changes necessary to keep patients safe,” said Lisa McGiffert, director of Consumers Union’s Safe Patient Project. “It’s time that hospitals make patient safety a higher priority.”
“I don’t know that I’m totally surprised by this,” added Diane Pinakiewicz, president of the National Patient Safety Foundation. Pinakiewicz said reporting hospital errors has only recently become expected practice, and that the focus has also been shifting toward identifying unexpected consequences of care— something of a gray area.
In correspondence published alongside the report, former Centers for Medicare and Medicaid Services head Dr. Donald Berwick said Medicare officials plan to develop a list of reportable events to help make it clear what hospital employees need to look out for.
Berwick wrote that the administration does not plan to issue any new reporting requirements. “The purpose of such lists should not include creating any new external adverse event reporting requirements, particularly since there are a number of states that have already put external reporting systems in place,” Berwick said in the letter.
Pinakiewicz said federal legislation would probably not be the best way to improve reporting of errors in hospital care. She said hospitals are already overburdened, and further reporting requirements—unless they were backed up by adequate resources—would unduly complicate an already complicated system.
The Obama administration has made the reduction of medical errors a priority. A report from the Institute of Medicine in 1999 estimated that medical errors kill as many as 98,000 people a year, and injure as many as a million.