86% of Adverse Patient Events Go Unreported in Hospitals

The US Department of Health and Human Services' (DHHS) Officer of the Inspector General (OIG) released a report on Friday, 6 January indicating that six in seven adverse events (AEs) that take place in hospitals go unreported.

The OIG's Director, Daniel Levinson, noted that all hospitals being paid under Medicare are obligated to "track medical errors and adverse patient events, analyze their causes" and make improvements to reduce future incidence of AEs. Levinson further noted that some of the most serious AE's, including death, were not reported through the incident reporting systems.

Levinson attributed the lack of reporting to a mix of factors, including being unfamiliar with the reporting system, assuming someone else had the responsibility to report, ignorance of what constituted an adverse event, and assuming that certain common adverse events did not need to be reported. All hospitals surveyed by OIG had reporting systems in place.

Roughly 14% of hospitalized Medicare beneficiaries experience an adverse event that necessitates a longer hospitalization, according to an earlier OIG report released in 2010. A further 14% experience an adverse event that requires additional treatment, but not further hospitalization.

The report recommends that the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) compile and provide a list of reportable events to hospitals, and that CMS draft guidelines on how to track and analyze adverse events.

• OIG - Hospital Incident Reporting Systems Do Not Capture Most Patient Harm
• NYTimes - Report Finds Most Errors at Hospitals Go Unreported