A new study released by the inspector general of the Department of Health and Human Services found that medical errors and adverse patient events are highly unreported, even those errors that lead to death.
Although hospitals have reporting systems for employees to inform management about adverse events, including medication errors, bedsores, hospital-acquired infections, and bleeding due to use of blood thinners—most are demonstrating a systemic failure of their reporting policies.
Hospitals receiving payments from Medicare are required to have a system that tracks medical errors and adverse events in order to improve care provided in hospitals.
The report’s findings—established by independent doctors who reviewed patients’ records nation-wide—estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in a single month while staying in hospitals. Out of 293 cases where patients were harmed, only forty were reported to hospital management, 28 were investigated and five led to changes in policies.
While it may seem like fear of disciplinary actions may keep employees from reporting events, it turns out that most employees actually do not recognize when harm is occurring or what events should be reported when a patient is harmed. In fact most employees did what people tend to do in their everyday lives—they figured someone else would report the event so they didn’t need to!
In order to remedy the underreporting of adverse events, Medicare officials plan on developing instructions that would list which events should be reported and how to report them. Why hasn’t this been done already?
In response to the staggering rate of hospital errors over half of the states have began requiring hospitals to publicly report infections that patients are developing in their hospitals. Will this force hospitals to seize accountability?
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