Self-Reporting the Next Frontier in Patient Safety




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Earlier this year, a report released by the Office of the Inspector General (OIG) discovered that 86% of adverse events go unreported in hospitals across the country. This was discovered as a result of events being reported on Medicare claims but not reported in the hospital’s incident reporting systems. A variety of reasons were given as to why this situation exists, including the inability of hospital staff to properly identify what constitutes patient harm.

To address this alarming issue, the Agency for Healthcare Research & Quality (AHRQ) has recently taken a significant and sure to be controversial step towards further uncovering the underreporting of adverse events in our nation’s hospitals. 

The agency filed a federal motion for government approval to design and test a new system that would effectively collect incident data directly from the patients, and according to AHRQ, would provide, “the unique perspective of healthcare consumers (that) could reveal important information that is not reported by healthcare providers.”

“While I recognize the government’s desire to get a more complete and accurate picture of adverse events taking place in our nation’s hospitals, I’m just not sure that asking patients to identify these events will yield the results the government is seeking,” says Hugh Morgan, VP of Quality for Somnia Anesthesia.

“It’s challenging enough getting patients to respond to basic questions asked about their hospital experience on HCAHPS satisfaction surveys let alone asking them to determine when and if they experienced some sort of adverse event during their hospitalization.

“The reality is that many adverse events go undetected to both patients and caregivers because the care providers can and do utilize care ‘work-arounds’ to essentially deflect or cover up the event. I think the government should continue to implement programs such as the Patient Safety Organizations in an effort to improve the nationwide culture of quality and safety among care providers so that there is a safe place for these providers to self-report and learn from these events.”   

Somnia Anesthesia

Blog Editor

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