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Report Finds Most Errors at Hospitals Go UnreportedBy ROBERT
PEAR
Published: January 6, 2012
WASHINGTON 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.
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Page 1 of 3Study of Medicare Patients Finds Most Hospital Errors
Unreported - NYTimes.com
3/5/2012http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-...
