An alarming new federal study finds that hospital employees report only one out of seven errors, accidents and other mix-ups that harm Medicare patients while they are hospitalized.
The New York Times reports that even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent these problems from happening again, according to the study by the Department of Health and Human Services (HHS).
Of the 293 cases in which patients had been harmed, federal investigators found that 40 were reported to hospital managers, 28 were investigated by the hospitals, but only five led to changes in policies or practices.
The study estimated that more than 130,000 Medicare patients experienced one or more of these “adverse events” in hospitals in a single month.
Daniel R. Levinson, HHS inspector general, noted that as a condition of being paid by Medicare, hospitals are supposed to “track medical errors and adverse patient events, analyze their causes” and improve care. Nearly all hospitals have some sort of reporting system to do this.
Unfortunately, Levinson said, “hospital staff did not report most events that harmed Medicare beneficiaries.” Some of the most serious problems, including some that caused patients to die, went unreported.
The types of problems hospitals are required to report include medication errors, severe bedsores, infections acquired while in the hospital, delirium from overuse of painkillers and excessive bleeding from improper use of blood thinners.
In the past, many experts said that hospital employees were often afraid to report mistakes.
But federal investigators say the main problem today is that hospital employees don’t recognize potentially harmful errors, or even realize that a particular problem harmed the patient and should be reported.
To clarify things, Medicare officials said they would develop a list of “reportable events” that hospital employees could use. The agency urged hospitals to give their employees clear, detailed instructions on the types of events that should be reported.
However, the problem may lie more with hospital management’s commitment to reducing medical errors, the federal study said.
Although hospital industry leaders say they place a high priority on reducing errors, at many hospitals this has not been translated into practice — or even a recognition that there could be a systemwide quality problem.
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