NCPA - National Center for Policy Analysis

Report Finds Most Errors at Hospitals Go Unreported

January 10, 2012

Federal investigators have found significant evidence of hospital employees failing to report many errors, accidents and other events that harm Medicare patients while they are hospitalized.  According to a study from Daniel R. Levinson, inspector general of the Department of Health and Human Services, administrators also often failed to adjust hospital practices to respond to those mistakes that were reported, says the New York Times.

  • According to the study, hospital employees report only one out of every seven mistakes/accidents that occur in the treatment of Medicare patients, including medication errors, severe bedsores, acquired infections, overuse of painkillers, and improper use of blood thinners.
  • The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.
  • When federal investigators did an in-depth review of 293 cases in which patients had been harmed, only 40 of those cases were reported to hospital managers, only 28 were subsequently investigated by the hospitals, and only five led to changes in policies or practices.

The top reason for the failure to report mistakes is up for debate, as the study suggests that it may have changed over time.  While the most common reason according to a 1999 study was that employees were afraid to admit having made a mistake, the most recent study found that failure to report resulted from a lack of awareness on the part of employees as to what constituted an error/accident.

With regard to the requirement that hospital administrators react to errors and mistakes by fixing hospital protocols, supervisors responded that many mistakes were considered to be non-systemic and therefore did not require adjustment.

Source: Robert Pear, "Report Finds Most Errors at Hospitals Go Unreported," New York Times, January 6, 2012.  Daniel R. Levinson, "Hospital Incident Reporting Systems Do Not Capture Most Patient Harm," U.S. Department of Health and Human Services, January 2012.

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