Hospital employees are not reporting most errors, accidents, and events that lead to serious harm to Medicare patients. The study released by the inspector general of the Department of Health and Human Services, Daniel R. Levinson, and reported in the January 6, 2012 issue of the New York Times. The report states that hospital employees are only reporting one out of seven of these adverse events. The report also comes to a conclusion that hospitals are rarely changing their practice and policies even after these adverse events, some leading to the death of patients, are reported
Although Medicare requires hospitals participating in the Medicare program must track medical errors and adverse events, analyze what the causes were, and take corrective action to help prevent similar events from occurring again, most hospitals are not taking these steps. Most hospitals are even set up with a system for employees to report adverse events, including medical errors leading to injuries, but very little is being done.
Adverse events include:
- Medication errors
- Severe bedsores
- Infections patients acquired in the hospitals
- Excessive bleeding from improper use of blood thinners
- Overuse of painkillers, causing delirium
The report estimates that more than 130,000 Medicare patients experienced at least one adverse event in hospitals in a single month. The reasons why the reporting of these events is so low includes employees believing the events were common and therefore, there is no reason to report them, thinking these were isolated events, assuming another employee would report the injuries, and not recognizing that these events actually harmed the patients.
The report finds that many hospitals do not believe these events demonstrated any systemic quality problems, and most have made very few changes to the way they practice or in policy change after discovering these events. Another problem is organizations that inspect these hospitals generally do not regulate how hospitals keep track of these types of adverse events, so there is no standard in place, and the problem continues uncorrected.
Although the Obama administration places a high priority on reducing adverse events like these, not much has changed with the way hospitals handle the policies to help prevent problems like this from reoccurring. One alarming statistic from the report demonstrates out of a thorough review of 293 cases in which patients had been harmed from medical errors, only 40 cases were reported to hospital managers, 28 cases investigated by the hospitals, and only 5 cases led to changes in hospital policies and practice.
There is an opportunity for improvement. At the end of year 2005, only 6 states had laws requiring hospitals to publicly report infections patients developed in the hospitals; now, at least 27 states have laws. Also, more than 2,900 hospitals have joined the administration in a "partnership for patients" to help reduce adverse events and save 60,000 lives in three years.