Survey: Many Patient Harm Events Unreported

A survey of 189 hospitals finds they all use incident reporting systems to capture events of patient harm, but that staff members don’t report 86 percent of such events.

The Department of Health and Human Services’ Office of Inspector General conducted the survey and makes findings and recommendations in a report made public on Jan. 5. “The administrators acknowledged that incident reporting systems provide incomplete information about how often events occur, but they continue to rely on the systems primarily because they value staff accounts of events,” according to the report.

Sixty-two percent of all events were not reported because staff did not perceive the incident as reportable, and 25 percent of events were ones that staff commonly would report, but did not in this particular case.

The report recommends that the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services jointly create a list of potentially reportable events and provide technical assistance to hospitals through guidance and training documents. Because hospital accreditors focus on how event information is used rather than how it is collected, OIG also recommends that CMS provide guidance on assessing the adequacy of event collection efforts.