A new federal report has found that only about 14 percent of all medical mistakes that harm patients in hospitals nationwide are ever actually reported.
Despite federal Medicare requirements that make reporting hospital accidents and mistakes mandatory, 86 percent of all harmful events go under the radar, according to a new report by the U.S. Department of Health and Human Services’ office of inspector general (DHHS-OIG).
In most cases, hospital staff appear not to have realized they should report the events, the study found.
Participation in the federal Medicare reimbursement program requires each participating hospital to track medical errors and adverse patient events and create incident reports for errors that result in patient harm. However, a review of 189 hospitals’ records nationwide by DHHS-OIG found that only one out of every seven patient harm incidents was properly reported. Most of the errors that did get reported were reported by nurses.
About 61 percent of the incidents were not reported due to staff members not knowing they should report them, hospital administrators told investigators. The remaining 25% that went unreported were cases where administrators claimed the staff commonly made a report, but failed in that particular instance.
Not only do the hospital error reports help the government track harm to patients caused by facilities nationwide, but they are also a key component in the development of new safety improvements to protect patients from future harm. However, the study also found that hospitals that successfully tracked such events rarely make changes to procedures to prevent a repetition of those events.
Hospital mistakes can include medication errors, allowing patients to develop bedsores, allowing hospital infections, wrong site surgery, leaving surgical tools and sponges in patients and other cases of medical malpractice.
The DHHS-OIG report recommends that the U.S. Centers for Medicare and Medicaid Services (CMS) work with the Agency for Healthcare Research and Quality (AHRQ) to create and promote a list of reportable events for hospital staff to reference. The report also urged CMS to strengthen hospital reporting system requirements and practices.
CMS reported that it is currently in development of guidance that would help assess patient safety improvement efforts in hospitals.