A study conducted by the HHS Office of Inspector General, Hospital Incident Reporting Systems Do Not Capture Most Patient Harm, analyzed the ways in which hospitals use incident reporting systems and incident reports to determine how accurately this reflected actual patient harm occurring within hospitals. The study also aimed to determine the extent of review by accreditors when assessing Federal requirements compliance.

Hospitals participating in the Medicare program must maintain a Quality Assessment and Performance Improvement program. While hospital administrators interviewed depended heavily on reports to track, analyze, and implement preventative actions for minimizing medical errors and adverse patient events, the study estimated that just 14 percent of patient harm events experienced by Medicare beneficiaries were captured. The remaining 86 percent were either not deemed reportable events by staff or were events usually reported but not in this instance.

The following conclusions and recommendations were made:

  • That AHRQ and CMS jointly devise and promote for hospital use a list of potentially reportable events;
  • That CMS guide assessment efforts by accreditors around hospital event tracking and analysis efforts;
  • That CMS recommend AHRQ’s Common Formats for use during surveyor evaluations; and,
  • That CMS work to improve event tracking through inspections of hospital compliance assessment survey standards.
  • Following draft comments from both AHRQ and CMS, both agreed to collaborate in building a potentially reportable events list and to offer hospitals guidance in using the same. CMS is drafting guidance for surveyors to boost patient safety.

To read or download the full report, click here  (PDF).