WASHINGTON D.C. — Hospital employees only report 14 percent of the events — including medical errors — that harm patients. And they typically don't make changes in how things are done that could improve patient safety, according to a study released Friday by the Inspector General in the Department of Health and Human Services, Daniel R. Levinson.
An independent review of patient records found the dismal reporting number, according to the Consumers Union.
By federal law, hospitals must track all medical errors and adverse events that hurt patients. They are also required to take preventive steps to protect patients. Medical errors and adverse events can include everything from giving a patient the wrong medication or dose to operating on a wrong body part to much less dramatic events.
Levinson told the New York Times that even some of the most serious errors, resulting in patient deaths, were not reported as required by the law. And the study found that only 5 of 293 reported cases of medical errors that were in the review led to changes in how things are done.
"Medical mistakes are one of the biggest problems we have in health care today," said Dr. Manny Alvarez, senior managing health editor of FoxNews.com, said in a story there. "We're beginning to see that with more monitoring, we are identifying more problems. The issue however, is that you have to learn from mistakes — and there are still many doctors and hospitals that do not do that."
"One in four hospital patients is harmed by medical errors and infections, which translates to about 9 million people each year," said Lisa McGiffert, director of Consumers Union's Safe Patient Project, in a written statement. "Today's report confirms what many other studies have already documented. Hospitals are doing a very poor job of tracking preventable infections and medical errors and making the changes necessary to keep patients safe. It's time that hospitals make patient safety a priority."
A 2010 study by the OIG said close to 180,000 Medicare patients a year experience medical errors in the hospital that contribute to their death. It also estimated that the cost of harm to Medicare patients each year is close to $4.4 billion.
While hospitals are required to report medical errors that cause harm to a patient, the information is usually not made public, for fear it would have a "chilling effect" on such reporting. Utah, for instance, is among many states that promise not to release the information publicly, in order to encourage reporting.
"To date, only aggregate data is released and not facility identifiable data," said Iona M. Thraen, patient safety director in Health Systems Improvement in the Utah Department of Health. "The goal of incident tracking is to identify risks and practices that can or need to be changed in order to prevent future occurrences."
Reporting the errors to officials is not all that's needed, McGiffert said. "Public reporting is what drives change and the public should have access to this critical information." She criticized OIG recommendations, saying they "take us down the tired and worn-out path of secret reporting of medical harm."
Not everyone agrees that public reporting is a good thing. A study published in the journal Pediatrics recently said that reporting improves when it's allowed in a "non-punitive" setting and the goal is improving patient safety.
For the study, the OIG sampled 189 hospitals, each with an incident-reporting systems to capture adverse medical events. Of those, 34 had reported events. "The administrators acknowledged that incident reporting systems provide incomplete information about how often events occur, but they continue to rely on the systems primarily because they value staff accounts of events," the report said. It noted that nurses most often report adverse events. And it said that hospital staff did not report 86 percent of events to incident reporting systems, "partly because of staff misperceptions about what constitutes patient harm." Of those not reported, 62 percent were not seen by staff as being reportable and 25 percent were "commonly reported," but not in the incident that was reviewed.
As to why cases were not reported, the OIG found that in 12 percent of cases the event was not caused by a perceptible error and in a like number of cases, it was an expected outcome or side effect. The event caused little harm or was ameliorated in 11 percent of cases. Other reasons for not reporting included not being on the mandatory reporting list (9 percent), frequent occurrence (8 percent), event symptoms seen after discharge (5 percent), patient had a history of similar events (4 percent) or unknown reasons (2 percent).
The OIG recommended that federal health care research and oversight agencies create a list of "potentially reportable events and provide technical assistance to hospitals in using the list."
It also suggested that the Centers for Medicare and Medicaid Services offer guidance to those who survey hospitals for the purpose of accreditation so they will consider how well the required reporting and tracking occurs.
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