Adverse Events in Hospitals
The HHS Office of Inspector General (OIG) has issued three reports on adverse events in hospitals, defined by the OIG as harm to a patient as a result of medical care. The first report, “Adverse Events in Hospitals: Overview of Key Issues,” identifies a number of areas integral to understanding the landscape of adverse events in hospitals, including the difficulty of measuring the incidence of adverse events, the importance of nonpayment policies for adverse events, barriers to adverse event reporting, legal concerns associated with public disclosure; and slow adoption of adverse event prevention recommendations. A second report, “Adverse Events in Hospitals: State Reporting Systems,” found that 26 states operated adverse event reporting systems as of January 2008. State strategies include legal protections to prevent improper disclosure, monetary penalties for failing to report, and feedback to hospitals about reported events. While specific reportable events and reporting criteria vary, most states use reported data in similar ways to hold individual hospitals accountable for their patient care performance and to promote learning and prevent adverse events. Finally, in “Adverse Events in Hospitals: Case Study of Incidence Among Medicare Beneficiaries in Two Selected Counties,” the OIG found that 13% of hospitalized Medicare beneficiaries in two selected counties experienced one of the four most serious categories of adverse events. The OIG notes that while “the results of this review are not nationally representative, the extent of adverse events and temporary harm found in this case study substantiates concerns about the incidence of adverse events in hospitals and the importance of safety initiatives to reduce occurrences.” The OIG will continue his work in this area.
