A report just released by the Department of Health and Human Services, Office of the Inspector General (OIG), reveals that while 60% of adverse and temporary harm events to Medicare patients occur at hospitals in states with event reporting systems, only 12% actually met the requirements for reporting and only 1% was actually reported to the state systems.
This recent report is on the heels of an even more alarming report released by the OIG back in January in which 2010 Medicare claims data revealed that approximately 27% of Medicare patients receive some sort of temporary or permanent harm during their hospitalization, yet only 14% of those events actually get reported in the hospital’s event reporting system.
The issue at hand in both reports doesn’t appear to be a matter of negligence, but rather the inability of hospital staff to recognize what actually qualifies as patient harm and not a side effect of the treatment.
“It’s absolutely unacceptable that hospital staff are either not being educated about the critical importance of event reporting or worse yet, that there exists this national culture of not simply identifying and learning from these events,” says Hugh Morgan, vice president of quality management for Somnia Anesthesia.
He continues, “We’re knee deep in this new era of Accountable Care that is rightfully focused on the quality and costs of care, yet the basics of identifying and learning from our mistakes to improve quality and prevent further harm seems to have alarmingly missed the mark across the country.”
Morgan concludes, “I see this as a real wakeup call for healthcare leaders who are truly committed to improving quality and outcomes because until we learn to embrace a culture of transparency and accountability when it comes to event reporting, I’m just not sure that we will collectively achieve the real, quantifiable quality that we all desire and that our patients certainly deserve.”