• OIG Finds Hospital Incident Reporting Systems Fail to Capture Most Patient Harm
  • January 12, 2012 | Author: Nancy C. LeGros
  • Law Firm: King & Spalding LLP - Houston Office
  • Medicare’s conditions of participation require providers to track and analyze adverse events and instances of patient harm and to take steps to prevent their recurrence.  According to a report released by the Department of Health and Human Services Office of Inspector General (OIG) on January 5, 2012, (OEI-06-09-00091), hospital incident reporting systems capture only an estimated 14 percent of patient harm events affecting Medicare beneficiaries.  According to OIG’s estimates, the remaining 86 percent of patient harm events are never reported by hospital staff, largely due to misconceptions about what constitutes “patient harm.”  One probable result of this report will be an increased focus on hospital incident reporting systems in future hospital surveys conducted by The Joint Commission and state surveyors.

    Surprisingly, the report failed to address the impact of the Patient Safety and Quality Improvement Act of 2005 (Pub. L. 109-41) (Act) on reporting of adverse events.  The Act was designed to promote increased reporting of patient safety incidents within the protected confines of a patient safety evaluation system, so that such incidents may be aggregated and analyzed to develop ways to improve patient safety.  Information reported within a patient safety evaluation system may be used only for activities designed to improve patient safety.  Such information cannot be accessed by agencies such as the OIG or CMS, or disclosed for purposes of malpractice litigation.

    OIG arrived at its estimates by analyzing incident reports collected from hospitals where previously-identified adverse events had occurred, and by interviewing hospital administrators.  OIG identified the adverse events while preparing a November 2010 report, available by clicking here, that analyzed the national incidence of adverse patient harm events among Medicare beneficiaries.  Physician reviewers reviewed the medical records of 780 randomly selected Medicare beneficiaries discharged during October 2008 to determine the nature and frequency of adverse events, the level of harm to the patient, and whether the event was preventable.  OIG concluded that approximately 1 in 7 Medicare beneficiaries (13.5 percent) experiences an adverse event during his or her hospitalization that results in prolonged hospitalization, requires life-sustaining intervention, or causes permanent disability or death.  An additional 13.5 percent experience temporary harm events that require treatment.

    This most recent report suggests that, of the adverse patient harm events identified in the 2010 report, fully 86 percent were never reported via the hospitals’ incident reporting systems.  Approximately 61 percent (of the total number of adverse events identified) were not perceived by hospital staff as reportable.  A further 25 percent were events of a type that were typically reported by staff, but were not reported in this instance.  OIG found that hospitals investigated two-thirds of all reported events, but made very few changes to hospital policies and practices as a result of the investigations.

    Nurses were the most frequent reporters, usually identifying reportable events through the regular course of care and also by completing hospital safety assessments designed to identify problems.  For one-quarter of the events investigated by OIG, however, information reported to the event tracking systems was not made immediately available to the staff responsible for monitoring patient safety.  Often, the staff was not made aware of the event until receiving an end-of-month aggregate event summary generated by the system.

    One focus of the report was to investigate how state surveyors assess hospital incident reporting systems during the accreditation process.  OIG found that surveyors usually evaluate incident outcomes rather than the methods hospitals use to collect information about adverse events.  Because hospital incident reporting systems are complex and varied, these systems have not been routinely scrutinized.  In its report, OIG urges CMS to provide guidance to accreditors regarding appropriate ways to assess the adequacy of hospitals’ incident reporting systems, including, specifically, hospital data collection efforts.  OIG suggests that the data elements on AHRQ’s Common Format event reporting tools should serve as a baseline for information collected by hospitals.  OIG also recommends that AHRQ and CMS collaborate to create a list of potentially reportable patient harm events, which could be used to educate hospital staff and assist administrators in evaluating and improving the usefulness and reliability of internal incident reporting systems.