OIG examines CMS methods for identifying adverse events

A report by the Office of Inspector General (OIG) report finds that the Center for Medicaid and Medicare Services may be failing to identify as many as 93% of adverse events in hospitals. 

Researchers analyzed the incidence of adverse events by reviewing a random sample of 278 Medicare patients and identified 120 adverse events. 

Key findings from the report:

  • The most effective way to identify adverse events is through review of medical records by nurses and/or physicians
  • Diagnosis codes were inaccurate or absent for 7 of the 11 Medicare hospital-acquired conditions identified by the case study, which could result in overpayments.
  • 93 percent of these events did not have any internal incident reports.  This could prevent hospitals from tracking events as required by regulation or reporting events to outside entities.

Recommendations for CMS and the Agency for Healthcare Research and Quality to effectively track and prevent events:

  • Explore opportunities to identify events when conducting medical record reviews for other purposes.
  • Provide interpretive guidelines for State survey agencies to assess hospital compliance with requirements to track and monitor adverse events
  • Inform Patient Safety Organizationss that internal hospital incident reporting may be insufficient

(SOURCES: Advisory Board Daily Briefing, http://advisory.com, March 5, 2008; Office of the Inspector General Report, http://oig.hhs.gov, March, 2010)