What’s New in the Patient Safety World

February 2012

OIG: Hospitals Fail to Recognize Most Cases of Harm



A report just released by the Office of the Inspector General (OIG 2012) found that, although all hospitals have incident reporting systems and other systems to identify adverse events, only 14% of hospital adverse events get reported. The commonest reasons given for lack of reporting were that the event was not related to an “error” or the event was considered to be an expected outcome or expected adverse event or that any harm involved was considered to be minor or temporary or simply that the hospital had no master list of reportable events. As in all studies of incident reporting, most reports are done by nursing and physicians seldom report adverse events. About a quarter of the adverse events were ones usually reported but were not reported in this instance.


A previous OIG report (Levinson 2010) showed that one in every seven Medicare patients who is hospitalized experienced adverse events during their hospital stays, up to 44% being potentially preventable (see our January 2011 What’s New in the Patient Safety World column “January 2011 No Improvement in Patient Safety: Why Not?”).


The current report was based on a random sample of almost 800 Medicare beneficiaries and used AHRQ Common Formats for identification of events that cause patient harm or near-misses. After identifying events they asked hospitals for any incident reports they had on these events. Hospitals were only able to confirm they had identified events in 14% of the cases identified by the OIG. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent).


The OIG report also asked state and local regulators and hospital accreditors about what they look for in hospitals as far as event reporting is concerned. Most reported that they look at how the incident reporting is used by hospitals, rather than how it is collected.


While all hospitals are familiar with the CMS list of “never events” and each state has its own list of reportable incidents, many hospitals are not familiar with the AHRQ Common Formats list. This was developed in collaboration with the National Quality Forum (NQF) and the federal Patient Safety Workgroup (PSWG) and includes incidents that reached the patient (whether or not harm occurred), near-misses, and unsafe conditions.


The OIG report recommends that AHRQ and CMS collaborate to create and promote a list of potentially reportable events for hospitals to use and that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events. It also recommends that CMS should suggest that surveyors evaluate the information collected by hospitals using AHRQ's Common Formats and CMS should scrutinize survey standards for assessing hospital compliance with the requirement to track and analyze events and reinforce assessment of incident reporting systems as a key tool to improve event tracking. Both AHRQ and CMS have responded that they will collaborate on a list and CMS also stated that it is developing draft guidance for surveyors regarding assessment of patient safety improvement efforts within hospitals.


In the interim, we’d suggest that you become familiar with the AHRQ Common Formats list!


Quite timely on the topic of failure to recognize actual or potential adverse events is an article in the Canadian Medical Association Journal (Daniels 2012). The authors looked at the impact of surveying families of children admitted to a Children’s hospital to see if they saw events they considered to be adverse events. A total of 321 events were identified in 201 of the 544 family reports received. Of these 48% were determined to represent legitimate patient safety concerns. Types of events most often included medication problems, miscommunications (between staff or between staff and families), and equipment problems. Only 8 of the adverse events reported were also reported by health care providers. There was also little change in reporting by health care providers after implementation of the family reporting system.


The Daniels article demonstrates that the perspectives of families and health care workers may differ regarding adverse events or near misses. Importantly, it shows that some of the barriers that prevent health care workers from reporting adverse events or near misses may not apply to families. Such family reporting systems therefore provide an opportunity (another set of eyes and ears) to identify potential patient safety issues in need of improvement.


Incidentally, in the Daniels study families noted that apologies were given only in a minority of cases but, when they were given, they were usually considered adequate. See our prior columns on disclosure and apology (June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It” and our November 2010 What’s New in the Patient Safety World column “IHI: Respectful Management of Serious Clinical Adverse Events).


Families responding to the surveys also readily volunteered to participate in future safety improvement initiatives by the hospital.


So in addition to removing barriers to adverse event reporting for staff, consider using other tools (such as the family adverse event reporting tool discussed above) to better identify patient safety concerns in your facilities. Such a tool may not only help you identify more opportunities to improve but likely also has a positive impact on patient and family satisfaction.






OIG (Office of the Inspector General. Department of Health and Human Services). Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. January 2012




AHRQ. Patient Safety Organizations. Common Formats.




Levinson DR. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090




Daniels JP, Hunc K, Cochrane DD, et al. Identification by families of pediatric adverse events and near misses overlooked by health care providers. CMAJ 2012; 184: 29-34

















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