Nearly 13 years after the release of the Institute of Medicine’s landmark report To Err Is Human, which called national attention to the rate of preventable errors in U.S. hospitals and galvanized the patient safety movement, six out of every seven hospital-based errors, accidents and other adverse events still go unreported.
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April 2012That’s the troubling conclusion of a report released in January by the U.S. Department of Health and Human Services’ Office of Inspector General (OIG). According to the OIG, the report, Hospital Incident Reporting Systems Do Not Capture Most Patient Harm, is the first truly national adverse event study documenting hospital-based adverse events among Medicare beneficiaries.
Previous studies assessing errors and adverse events had tracked the number of events reported but had no denominator; in other words, one hospital might have 1,000 reports of adverse events and errors in a given month, while another might have 50, but there was no way to know how many adverse events had been missed and how much harm had actually occurred. But this OIG study dug deeper, conducting in-depth year-long reviews led by independent physicians to first identify the rates of harm, then returning to the hospitals in the study where they knew harm had occurred to find out if incidents had been reported or not.
Overall, the inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. Perhaps one of the most surprising findings: Even some of the most serious, egregious adverse events were not reported. Of the 12 deaths in the sample that were iatrogenic, only two were actually reported as errors. More serious errors were no more likely to be captured as errors than mild reactions like breaking out in hives caused by a medication.
Why aren’t more hospital-based errors and adverse events being reported, and how can this situation be changed? The OIG’s report provides some insight into the underlying problem. The dominant reason that events weren’t reported was that they weren’t perceived as adverse events. (Not all adverse events are medical errors: A medical error is a preventable adverse event.) A urinary catheter infection, while not necessarily a medical error, is always an adverse event, yet only one of the 17 urinary catheter infections identified by doctors in medical review was reported.
Reasons
Lack of recognition. Seeing adverse events and errors as just part of routine care is only one part of the problem, said Rosemary Gibson, MSc, a former senior program officer at the Robert Wood Johnson Foundation and coauthor of The Treatment Trap: How the Overuse of Medical Care Is Wrecking Your Health and What You Can Do to Prevent It (Lifeline Press, 2010) and Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans (Lifeline Press, 2003). Other issues include: