A new report released Friday by the inspector general of the U.S. Department of Health and Human Services found that more than 80 percent of hospital errors go unreported by hospital employees. The report, which looked at data from hospitalized Medicare patients, also found that most hospitals where errors were reported rarely changed their policies and practices to prevent repeat errors, saying the event did not reveal any “systemic quality problems.”
The errors included overused or wrong medications, severe bedsores, hospital-based infections and even patient death. In order to be paid by Medicare, hospitals are required to track and analyze medical errors. But organizations that inspect hospitals loosely regulate hospital tracking records, the study said. Additionally, many hospital employees may not recognize “what constitutes patient harm,” or they may not realize that particular events harmed patients and should be reported, according to the report.
The national report looked at nearly 300 adverse patient events acquired from medical records and traced the records back to its respective hospitals to see whether the hospitals had identified medical error. The report found very few hospitals did.
Sixty-one percent of unreported cases were not perceived as errors by hospital staff. The remaining 25 percent of unreported cases were situations that were typically reported by the staff, but happened not to be reported. Forty-four percent of the errors identified were preventable.
Interestingly, the more serious events, like hospital-acquired infections and patient deaths, were no more likely to be reported than the smaller cases, like allergic reactions to medications.
The study is one of many finding similar results. In April 2011, a study released in the journal Health Affairs found that one third of hospital visits will lead to hospital related injuries, and as many as 90 percent of hospital errors are missed by current surveillance systems. The Center for Medicare Services plans to develop and distribute a list of adverse events that should be reported.