Hospital incident reporting systems only capture about 14% of patient harm events experienced by Medicare beneficiaries, says a new report by the Office of Inspector General (OIG) of the Department of Health and Human Services. Events are underreported in part, says OIG, because of staff misperceptions about what constitutes patient harm. In the absence of clear event reporting requirements, administrators classified 86% of unreported events as either events that staff did not perceive as reportable (62% of all events) or that staff commonly reported but did not report in this case (25%).
In OIG's investigation of 189 hospitals, all hospitals reported using incident reporting systems designed to capture instances of patient harm, although administrators acknowledged that information about how often events occur is incomplete. The investigation also revealed that nurses most often reported events, typically identified through the regular course of care.
To help educate hospital staff about the full range of patient harm that occurs in hospitals and assist hospital administrators in assessing incident reporting systems, OIG recommends that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services (CMS) collaborate to create a list of potentially reportable events and provide technical assistance to hospitals in using the list. The agencies could promote the list through guidance and training documents aimed at hospitals, other health care settings, clinical education settings, and guidance documents for state and accrediting surveyors.
Because hospital accreditors tend to focus on how event information is used rather than how it is collected, OIG also recommends that CMS provide guidance to accreditors regarding surveyor assessment of hospital efforts to track and analyze events and scrutinize survey processes when approving accreditation programs.
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