Aaron J. Freiwald
Hospitals Under-Report “Adverse Events”

No one should be surprised to learn that medical errors occur in hospitals, even the finest medical centers.  The extent to which hospitals fail their legal obligation report “adverse events,” however, is shocking.

According to a recently released report from the Office of Inspector General (OIG) for the Department of Health and Human Services, in the nearly 200 hospitals surveyed, hospital staff failed to report 86 percent of adverse events to incident reporting systems.  Here is a link to the full report: http://oig.hhs.gov/oei/reports/oei-06-09-00091.asp.

As a condition of participation in Medicare, hospitals are required to track, analyze and report adverse events, which are defined as occasions when harm to a patient results from medical care.  Although an adverse event may occur in the absence of a medical error – whether an error with a prescription, or a failure to perform a procedure correctly or inadequate monitoring – the fact is that many adverse events do result from error.There are two clear problems with hospitals lack of vigilance when it comes to incident tracking and reporting.  First, quality of care in hospitals is a legitimate concern for those interested in improving patient safety.  The OIG report demonstrates that, at least as is reflected in incident reporting, we are not fully appreciating just how much health care quality is an issue.

Second, one of the goals of incident tracking and reporting is to provide a vehicle for hospitals to improve patient safety.  The OIG report cites federal regulations that require hospitals to “track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.”

Many times when I take the deposition of a physician or a nurse in a medical malpractice case, I ask what steps were taken to review with the personnel involved the circumstances of our client’s care so that those involved can learn from the experience and avoid the same thing happening in the future.  Many, many times the answer in response is: Nothing.  Many times, I will hear that the physician did not even speak with the nurse.  The resident (trainee) never spoke about the event with a supervising physician.  No one sat down to review the hospital policy to see that it was appropriate or make sure it was being enforced.

The OIG report underscores the critical need for health care providers to be more accountable for the safety and well-being of their patients.