Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized, federal investigators say in a new report.
Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the “adverse events,” according to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services.
In the report, being issued on Friday, Mr. Levinson notes that as a condition of being paid under Medicare, hospitals are to “track medical errors and adverse patient events, analyze their causes” and improve care.
Nearly all hospitals have some type of system for employees to inform hospital managers of adverse events, defined as significant harm experienced by patients as a result of medical care.
“Despite the existence of incident reporting systems,” Mr. Levinson said, “hospital staff did not report most events that harmed Medicare beneficiaries.” Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.
Adverse events 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.
Federal investigators identified many unreported events by having independent doctors review patients’ records.
The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.
Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said.
When the National Academy of Sciences issued a landmark report on patient safety in 1999, many experts said that hospital employees were often afraid to admit mistakes. But that no longer appears to be the main obstacle to reporting, federal investigators said.
More often, Mr. Levinson said, the problem is that hospital employees do not recognize “what constitutes patient harm” or do not realize that particular events harmed patients and should be reported.
In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or “suspected that the events were isolated incidents unlikely to recur.”
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3 Responses
And you have to keep a close eye on your loved ones in the hospital all the time, don’t be afraid to ask the dr. any question or explanation, and don’t be afraid to check with the nurse which medication she’s feeding the paitient or injecting in the iv, many patients lost their lives “accidentally” cuz they were given the wrong medication.
Waht protion of errrors the hoppen in the world outside hospitals go unreproted?
I can personally attest to the truth of this article having seen it with my own eyes. I think 1 in 7 is understating the problem! With my mother they made many more than 7 mistakes and none were ever reported. When we tried to do anything we were threatened that we would not be able to stay with her round the clock which she very much wanted us to do. I still feel sick when I think about the horror of her hospitalization. Btw she went in for a simple procedure and never came home due to all the errors and neglect!