Half of the states require hospitals to report adverse medical events involving patients, but few are actually complying, a new watchdog report says. The lack of reporting undercuts an important safeguard and monitoring system for medical mistakes.
Hospitals disclose to state authorities few of the adverse events suffered by Medicare patients despite legal reporting requirements, undercutting an important safeguard against medical mistakes, a federal investigation has found.
The Department of Health and Human Services inspector general’s review concluded most of the adverse events – bad reactions, medical mistakes or unexpected symptoms – aren’t even being caught by the hospitals’ own monitoring systems.
“Low reporting to state systems is more likely to result from hospital failure to identify events than from hospitals’ neglecting to report known events,” the inspector general’s report released late Friday concluded.
A spokesman for the American Hospital Association, the industry’s main trade group, did not immediately respond Sunday for a request for comment.
The HHS watchdog undertook the study after an earlier investigation in 2008 found that 13.5 percent of hospitalized Medicare beneficiaries experienced serious adverse events, and an additional 13.5 percent suffered reactions that caused temporary harm.
The new report portrays an unreliable honor system that is supposed to track and alert authorities to medical reactions and mistakes.
In a small sample, ”hospitals reported only 3 of the 35 events required to be reported to a state reporting system,” the inspector general noted.
The three incidents that were reported were less serious, and all of the more serious events uncovered by the IG went unreported at both the hospital and state levels, the report said.
“ Six of the 32 events contributed to patient death, including cases involving lack of patient monitoring and missed diagnoses,” the report said, citing one example of acute renal failure caused by the hospital not recognizing a serious bacterial infection and another in which poor hospital management of insulin led to a hypoglycemic coma.
“Other unreported events required the use of life-sustaining interventions, indicating that hospital staff were clearly alerted to a problem but still did not report the events,” the watchdog disclosed.
Inspectors general are the independent watchdogs who police against waste, fraud, abuse and corruption in major federal agencies and government programs.
The Department of the Health and Human Services is the Cabinet-level federal agency that government health policy and medical research.
Medicare is the main federal health insurance program for senior citizens.