Reporting on Patient Harm: Work Still to Be Done

By Jennifer Larson, contributor

July 27, 2012 - Transparency in health care has been recently touted as a key issue among industry leaders and politicians alike, yet the latest report from the U.S. Office of Inspector General (OIG) on the reporting of adverse events in hospitals shows that there is still a lot of work to be done.

The report, which was released July 19, looked at data on Medicare beneficiaries who were discharged in October 2008.  The report built on earlier work that examined data from 2008, when about half of the states had some type of adverse event reporting system in place.

The findings: an estimated 60 percent of patient harm events occurred in hospitals in states that had reporting systems. However, only 12 percent of those adverse or temporary harm events met state requirements for reporting. 

Additionally, according to the report, hospitals only reported about 1 percent of adverse and temporary harm events.

This is not a new issue. The Institute of Medicine’s (IOM’s) seminal To Err Is Human report, published in 2000, called for a national public mandatory reporting system that would identify errors and adverse events. However, 12 years later, we are still lacking that kind of system at the national level.

Since 2000, more--but not all--states have implemented reporting systems. A June 2011 report from the Centers for Medicare and Medicaid Services (CMS), titled Update on State Government Tracking of Health Care-Acquired Conditions, noted that 27 states and the District of Columbia have “enacted legislation to establish adverse event reporting systems.” However, there is quite a bit of variation even in these programs, and the lack of standardization and variability has caused concern among many leaders and stakeholders in the health care industry. 

In addition, some studies have shown that voluntary reporting systems tend to miss numerous events. For example, a study published in Health Affairs in April 2011 found that voluntary reporting systems tend to significantly undercount adverse events. And just this past January, a study released by the OIG stated that most hospitals’ reporting systems aren’t flagging nearly enough adverse events--in fact, they miss about 86 percent of harmful inpatient adverse events.

Are hospitals deliberately not reporting harmful or adverse events, or are they failing to identify events that should be reported? The latest OIG memorandum theorized that it’s probably the latter. The report noted that “low reporting to State systems is more likely the result of hospital failure to identify events than from hospitals neglecting to report known events.”

What could help?

Would a “must-report” list help some hospitals better identify adverse events and actions that have caused patient harm? The OIG’s January report made that recommendation. The Agency for Healthcare Research and Quality (AHRQ) and CMS are currently working on just such a list, which is expected to be released at the end of August.  

Frank Federico, RPh, executive director, strategic partners, for the Institute for Healthcare Improvement (IHI), noted that hospitals could improve by implementing tools or methods that are designed to help them identify adverse events more reliably.

After all, it can be difficult “in the thick of things” and some people may actually not realize that an adverse event has occurred as the result of an action they took or didn’t take. For example, say that you’re a clinician dealing with a stressful or emergent case, just trying to stay on top of the situation. So you may not identify a problem as a result of the care that you’ve just been providing. As Federico noted, “it’s not being held to the same interpretation as when you’re doing a chart review later.”

IHI is known for its Global Trigger Tool, although Federico said that some hospitals are successfully using other improvement methodologies, such as Six Sigma or Lean. The April 2011 Health Affairs study on adverse events found that organizations that used the Global Trigger Tool were able to identify ten times more “confirmed significant” events than other commonly used methods, including voluntary reporting and AHRQ’s Patient Safety Indicators.

Federico suggested that hospital leaders make sure they understand the extent of adverse events and errors that are happening in their facilities. Then they can make changes to their systems that focus on prevention and can reduce the likelihood of adverse events occurring.

“Get a real handle on the harm that is occurring in your organization,” he said.

Keeping track of physician involvement

Sidney Wolfe, MD, director of the Health Research Group for Public Citizen, is concerned about what he calls the lack of vigilance in detecting and reporting of adverse events by hospitals. One major problem, he said, is the lack of discipline for physicians who contribute to harm or adverse events.

The Health Resources and Services Administration (HRSA) began operating a National Practitioner Data Bank (NPDB) after Congress passed a law in 1986. Essentially, the database is an “information clearinghouse” that compiles any actions taken against the license of a health care practitioner, and any negative actions or findings taken against him or her by a peer review organization or accrediting organization.  The general public can’t request information about a practitioner, but hospitals and state licensing bodies, among others, can query the database.

Public Citizen has been concerned for several years that hospitals are not reporting their physicians to the NPDB when it’s appropriate to do so.

“They aren’t getting reported because there’s a culture of giving people more chances,” Wolfe said. “Other than the patient, of course.”  

Just because a physician is involved in a harm event doesn’t mean that punishment is necessarily merited, he added. But incidents should still be noted and reported.

The future?

Will reporting rates improve in the future? That remains to be seen.

IHI’s Federico is optimistic. “I believe that reporting will improve. It will take time,” he said. “The aviation safety reporting system became more effective as time went on and the airline industry found that improvements resulted from the reports.”