In order for a hospital to participate in the Medicare program, it must develop and maintain a Quality Assessment and Performance Improvement (QAPI) program to “track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.” However, a new study by the Dept. of Health & Human Services found that only a small portion of patient errors are being reported — and that hospitals don’t seem to give a damn about fixing things.

According to a report from the HHS Office of the Inspector General, hospital incident reporting systems only captured about 14% percent of “patient harm events” experienced by Medicare beneficiaries.

“Hospitals investigated those reported events that they considered most likely to lead to quality and safety improvements and made few policy or practice changes as a result of reported events,” states the report. “Hospital administrators classified the remaining events (86%) as either events that staff did not perceive as reportable (61%) or as events that staff commonly report but did not report in this case (25%).”

HHS says that all the hospitals involved in the study had incident reporting systems and that the administrators at these facilities all claimed to rely heavily on these systems to identify problems.

“One in four hospital patients are harmed by medical errors and infections, which translates to about 9 million people each year,” said Lisa McGiffert, Director of Consumers Union’s Safe Patient Project. “Today’s report confirms what many other studies have already documented. Hospitals are doing a poor job of tracking preventable infections and medical errors and making the changes necessary to keep patients safe. It’s time that hospitals make patient safety a higher priority.”

The Inspector General’s report recommends that the Centers for Medicare and Medicaid Services (CMS) provide hospitals with a standard list of medical errors that need to be tracked and reported to the agency.

And while that would be a good start, Consumers Union believes that public reporting of medical errors is crucial to making hospitals accountable.

“Hospitals should be pushed to do a better job at tracking medical harm, but public reporting is what drives change and the public should have access to this critical information,” said McGiffert. “The solutions arrived at in this report take us down the tired and worn out path of secret reporting of medical harm.”

In 2010, the Inspector General estimated that 15,000 Medicare patients per month experienced medical errors in a hospital that contributed to their deaths. Annually, that adds up to around 180,000 patients. That study estimated the annual cost for these events in hospital care alone at $4.4 billion.

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm [HHS.gov]

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