One in seven. According to a new report by federal investigators, that is how often hospital employees both recognize and report errors and other adverse events that injure Medicare patients.
The figure is shockingly high. It raises troubling questions about the extent of medical malpractice in South Carolina and across the country.
The report was overseen by Daniel R. Levinson, the inspector general of the of Health and Human Services department. He noted that some of the most serious adverse events, including many that led to patient deaths, were not reported at all.
Even for those injuries that are reported, hospitals often fail to take action to change the practices that caused them. The HHS inspector general’s report was based on a review by independent doctors of the patient records of Medicare patients.
The investigators performed detailed reviews of 293 cases of patient harm. Only 40 of those cases had been reported to hospital managers. Hospitals investigated 28 of those, but only five cases led to changes in policies or procedures.
During the investigation, numerous hospital administrators admitted that their employees were underreporting errors. As a result, there tends to be a repetition of the same types of injuries, including those involving medication errors, bedsores, and hospital-acquired infections. Another common problem is overuse of painkillers, which causes delirium. Improper blood thinner usage that causes excessive bleeding is a recurring problem as well.
The report found that fear of admitting mistakes is not the main factor in the underreporting of medical errors. Hospital employees need better training about what harm to patients involves. Medicare officials intend to draft a set of detailed instructions to better guide the reporting.
Source: “Report Finds Most Errors at Hospitals Go Unreported,” New York Times, 1-6-12