Historically, traditional payment policies – coupled with lax oversight by regulators, weak leadership from many corners of the hospital and physician communities, and an uninformed, reverential public – have served to perpetuate (sometimes even reward) the use of unsafe practices and antiquated technologies in the hospital industry. This, in turn, resulted in a frightening number of adverse events – instances where patients are harmed by medical care. The consequences are tens of thousands of deaths and millions of injuries – the vast majority quite avoidable.
Fortunately, reduction of adverse events is now a priority. This is led by new payment and reporting policies by Medicare and some state Medicaid programs, influential players like IHI and the Leapfrog Group, the Hospital Quality Alliance, and a growing demand for disclosure of hospital and physician performance. Through realigned payment policies, public reporting of adverse events, and readily available best practices, hospitals are being given powerful new incentives to use safer practices.
Key Issues in Adverse Event Reporting by Hospitals:
The HHS Office of the Inspector General (OIG) has identified key issues affecting reporting of adverse events in hospitals:
- Estimates of the incidence of adverse events in hospitals vary widely. Measurement remains difficult, although methods and tools to support proper reporting are advancing quickly.
- Nonpayment policies for adverse events are gaining in prominence. Stakeholders see this as a powerful incentive to reduce preventable medical errors. However, there are potential drawbacks, such as perhaps discouraging hospitals from admitting complex cases and encouraging gaming in reporting.
- Hospitals heavily rely on managers and staff to report adverse events internally, but barriers (cultural, organizational, physician relations, etc.) often inhibit reporting.
- Hospitals report adverse events to various oversight entities. However, experts suspect substantial underreporting.
- Public disclosure of adverse events benefits patients but also raises liability concerns.
- Information on how to prevent adverse events is widely available. Nonetheless, many hospitals and clinicians are slow to adopt or use recommended patient safety practices.
The OIG believes we are finally “on the threshold of accelerated progress” in reducing the incidence of adverse events in hospitals. Yeah, their optimism is heavily couched but there has been some genuine progress. The OIG identifies a series of strategies that could hasten this.
For the OIG report on key issues in reporting and reducing adverse events in hospitals, click here (PDF).
State Requirements for Reporting Adverse Events:
Today, 26 states now have adverse event reporting programs. The Institute of Medicine (IOM), which supports mandated reporting, says reporting helps hold individual hospitals accountable for performance while providing information to improve patient safety and save lives. States vary somewhat by the list of reportable events and criteria for identifying reportable events. Most of the 26 state systems focus on adverse events in hospitals but some also require or support reporting in other care settings.
Most states told the OIG that “hospitals do not always report when adverse events occur.” Underreporting is apparently common and probably substantial. To encourage better reporting, states have implemented various strategies. For example:
- Legal protections to prevent improper disclosure.
- Monetary penalties for failing to report an adverse event.
- Giving feedback to hospitals about reported events.
- Audits or state-led investigations of the hospitals’ handling of reported events.
- Promote learning through reports, training, and patient safety bulletins and alerts.
For the OIG report on state reporting programs, click here (PDF).