Hospital incident reporting systems have been found to capture as few as fourteen percent of adverse medical events, according to a report by the Office of the Inspector General.
For the report, investigators examined medical records of adverse events in Medicare patients from 189 hospitals in October 2008. Key findings from the report:
- All sampled hospitals had incident reporting systems to capture events, and reported using these systems to identify problems.
- Many events were found to be unreported on the hospital incident reporting systems because there were no clear guidelines on which incidents are reportable.
- Even when events were reported in the system and investigated, few policy changes were made to improve patient safety.
The OIG recommends that AHRQ and CMS should work together to create a list of potentially reportable events and provide technical assistance and guidance to hospitals in using the system and analyzing data.