The New York Times reported on January 6th the results of a study undertakenby the inspector general of the U.S. Department of Health and Human Services (HHS)that reveals that hospital employees report only one in seven events that harm patients. The new report issued on Friday was issuedin connection with a study on whether hospitals are complying with the Medicare requirement that hospitals "'track medical errors and adverse patient events, analyze their causes' and improve care." Adverse events are defined broadly to include "medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners."
According to Daniel Levinson, inspector general of HHS, approximately 130,000 hospitalized Medicare beneficiaries suffer adverse events each monthand that the problem of under- reporting is multifactoral. Hospital employees either do not recognize "'what constitutes patient harm' or do not realize that particular events harmed the patient and should be reported." In other cases, hospital employees recognized that an adverse event had occurred, but assumed someone else would report it, or that the event was so isolated that reporting was not required. Medicare officials are now developing a list of "reportable events" and are encouraging hospitals to better train their employees on those events that should be reported.
The Obama administration has placed a high priority on reducing medical errors.More than 2,900 hospitals have agreed to participate in a "partnership for patients" with the goal of saving 60,000 lives over three years. Despite the cooperative spirit, the Times story reveals that hospital managers have not implemented quality control changes in response to clear evidence of"systemic" institutional problems with patient care.
It appears President Obama is again fulfilling a promise to improve the quality of health care in the United States. Hospitals are now coming to terms with thequid pro quofor receiving payments from Medicare. It's a shame that institutions must be watched and reminded of their obligation to report adverse events and to improve the quality of the care they provide. The HHS report makes clear that hospitals must pay more attention totheir own internal data, train their employees better on what must be reported and to whom,and make improvements on the quality of the health care they render.