CMS Inspectors fail to report hundreds of serious reportable events

Hundreds of serious healthcare errors go unreported each year because Medicare inspectors who found problems at hospitals did not report them , according to a report by the Inspector General.

The report examined the Center for Medicare and Medicaid Services’ response to serious reportable events including medication errors, surgical errors, and patient assault.  Key findings from the report:

  • Despite its policy, CMS inspectors failed to report many serious events to the Joint Commission and other national agencies.
  • State agencies and CMS often failed to review hospitals' compliance to CMS’s Conditions of Participation on quality assessment and performance improvement.
  • State agencies and CMS inspectors performed few long term follow ups to verify that hospitals' corrective actions resulted in sustained improvements.

The report concludes that in order for hospitals to learn and make changes stemming from serious reportable events, inspectors and state agencies must report events and state agencies must monitor hospital improvement efforts.


(Sources: Office of the Inspector General Report,, October 31, 2011; Kaiser Daily Health Policy Project,, November 1, 2011; USA Today,, November 1, 2011)