According to a recent federal investigation by the Department of Health and Human Services, only one out of every seven hospital errors goes reported. Even after the errors are reported, hospitals fail to change their practices to prevent repeated adverse events.
Reporting of hospital errors provides essential information for hospitals and medical professionals about areas in which need improvement. Medicare payment includes a requirement that the hospital “track medical errors and adverse patient events, analyze their causes” and improve care. Virtually all hospitals have systems whereby hospital employees can report harm experienced by patients as a result of medical care. However, hospital staffs did not report events that harmed Medicare beneficiaries, including patient deaths.
Only 26 states currently require hospitals to publicly report egregious errors, such as operating on the wrong patient, the wrong body part, or leaving a surgical tool inside the patient. The Centers for Disease Control and Prevention estimate that nearly 2 million patients contract an infection during a hospital stay each year. An investigation by the Los Angeles Times revealed that many errors that resulted in patient deaths at the hospital remained secret for more than a decade, sometimes even unknown to the patient’s families.
The Department of Health and Human Services estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. According to federal investigators, the reason that these adverse events go unreported is no longer due to fear by the hospital employees. In some cases employees assume someone else will report the episode, believe they are common errors that need not be reported, or that they are isolated events that do not reveal systematic treatment problems. Assuming that many errors are isolated events that do not reveal systematic treatment problems, hospitals do not change their practices or policies even after the harms to patients are reported. According to the federal investigation, out of 292 cases in which patients were harmed, 40 of those were reported, 28 were investigated, and only 5 led to changes in policies or practices.
To clear up this confusion, Medicare officials said they would develop a list of reportable events that hospitals could use as well as detailed instructions on what types of events should be reported. At least 27 states have laws that require hospitals to report publicly on infections that patients develop in hospitals. The Obama administrations declined to propose new federal requirements for the public reporting of adverse events.
