Most Hospital Errors are Not Reported

Federal investigators released a new report stating that hospital employees are only reporting one out of seven errors, events, and accidents that are harming Medicare patients while they are hospitalized, as reported in the New York Times, January 6, 2012.  Daniel R. Levinson, inspector general of the Department of Health and Human Services released the study coming to the conclusion that hospitals are rarely changing their policies, even after preventable injuries and infections have been reported, some errors even resulting in the death of patients.

Hospitals that are paid under Medicare must track medical errors and adverse patient events, analyze the causes and improve the care to avoid repetition of similar mistakes.  Most hospitals are equipped with a system for employees to inform hospital managers of adverse events which cause significant harm to patients.  These adverse events include severe bedsores, medication errors, patients who were infected while in the hospitals, excessive bleeding from blood thinners, and overuse of painkillers resulting in delirium.

The inspector general's report estimates that over 130,000 Medicare patients experienced one or more adverse events in hospitals in a single month.  Employees are under-reporting these adverse events for many reasons, including:

• Not recognizing what constitutes patient harm
• Not recognizing that these events actually harmed patients and should be reported
• Assuming another employee would report the injuries
• Employees thought these were isolated events and would not likely reoccur
• The adverse events were so common there was no need to report them

Most hospitals did not believe these adverse events demonstrated any systemic quality problems.  Most hospitals made few changes to their practices or policies after detecting these adverse events either. Hospitals that are inspected are generally not scrutinized as to how they keep track of adverse events leading to serious injuries, so the problem is often not corrected.

The Obama administration has placed a high priority on reducing medical errors that lead to injuries; however, not much of this priority has produced needed changes in hospitals.  For example, the report states that out of a detailed review of 293 cases in which patients had been harmed due to medical errors, only 40 cases were reported to hospital managers, 28 cases were investigated by the hospitals, and only five cases led to changes in the way hospitals practiced or in hospital policy changes.

However, there is hope.  Over 2,900 hospitals have joined the administration to reduce errors, with a goal to save 60,000 lives in three years.  Also, while only 6 states had laws requiring hospitals to report publicly regarding patient infections developed in the hospitals at the end of 2005, now at least 27 states have added the laws.