The Office of the Investigator General (OIG) for the Department of Health & Human Services published a report a few weeks ago titled, “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm,” in which an in-depth study of adverse event reporting in almost 200 hospitals disturbingly revealed significant underreporting of adverse events and incidents. The study reported that an astonishing 86% of Medicare adverse and temporary harm events go unreported to CMS due to a host of reasons including staff misperceptions as to what constitutes patient harm and unremarkable patient outcomes that were ultimately not affected by the adverse event. What’s more is that this report is on the heels of a 2010 study in which the OIG found that 13.5 percent of hospitalized Medicare beneficiaries experienced adverse events with an additional 13.5 percent experiencing temporary harm events that required treatment. So in reality, approximately 27% of all Medicare patients experience some sort of hospital related event resulting in additional treatment and/or prolonged hospitalization.
“This is unconscionably alarming”, says Hugh Morgan, Director of Quality for Somnia Anesthesia and the company’s Patient Safety Organization. “This era of health reform is very much focused on quality and safety, but it’s clear that the numbers that really matter, the numbers that are affecting patients, are simply not being reported.” Mr. Morgan adds, “CMS has terrific, value-add quality and safety programs such as participation as a Patient Safety Organization, but these programs are voluntary and often require extensive resources that present incident reporting obstacles for most organizations. At Somnia, we have developed a non-punitive culture of continuous self- assessment through which our clinicians are accountable and committed to 100% incident reporting that is reconciled daily by our clinical and administrative leadership. Our clinicians recognize their honest and valued contributions to raising the national bar of quality and safety, which is further validated thru Somnia’s participation with the Anesthesia Quality Institute and recent recognition as a Patient Safety Organization.”