Being admitted to a hospital is a scary proposition. Although most patients who are advised to be admitted to a hospital to correct a health problem realize the necessity, they are fearful of a bad outcome. Those fears are not unfounded; according to a report issued by the U.S. Department of Health and Human Services (HHS) on January 6, hospital personnel recognize and report only one out of seven errors, accidents, and other events that can harm Medicare patients while they are hospitalized. The study was conducted by Daniel R. Levinson, inspector general of HHS.
The study noted that even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the “adverse events.” Mr. Levinson explained that for a hospital to receive Medicare reimbursement it is required to track medical errors and adverse patient events, analyze their causes, and improve care. Virtually all hospitals have some type of system in place for the hospital staff to inform management 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 noted, “hospital staff did not report most events that harmed Medicare beneficiaries.” Furthermore, he noted that, some of the most serious problems, including some that resulted in a patient’s death, were not reported.
HHS investigators identified many unreported events by having independent doctors review patient records. Mr. Levinson estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. He added that many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in their hospital.
When the National Academy of Sciences issued a landmark report on patient safety in 1999, many healthcare analysts noted that hospital employees were often afraid to admit mistakes. However, that obstacle no longer appears to be the main reporting issue, noted the HHS investigators. Mr. Levinson explained that in most cases, the underreporting is due to the hospital staff’s failure to recognize “what constitutes patient harm” or do not realize that particular events had resulted in patient harm and thus, needed to be reported. He added, that in some incidents, employees assumed that someone else would report the adverse event, 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.
In order to reduce confusion over what constitutes and adverse event, Medicare officials plan to develop a list of “reportable events” that hospitals and their employees could use. In addition, they noted that hospitals should give employees “detailed, unambiguous instructions on the types of events that should be reported.”
The report acknowledged that the Obama administration and hospital industry leaders have placed a high priority on reducing medical errors; however, at many hospitals, this high-level commitment has not been translated into practice.
Although the HHS report is disturbing, Los Angeles residents should be reassured that they have access to one of the best hospitals in the nation: the UCLA Health System. The facility has a long-standing reputation for providing comprehensive care and strives to minimize errors that could result in patient harm.
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