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.
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: