Nearly 13 years after the release of the Institute of Medicine’s landmark report To Err Is Human, which called national attention to the rate of preventable errors in U.S. hospitals and galvanized the patient-safety movement, 6 out of every 7 hospital-based errors, accidents, and other adverse events still go unreported.
Explore this issue:July 2012
That’s the troubling conclusion of a report released in January by the Department of Health and Human Services’ Office of the Inspector General (OIG). According to the OIG, the report the National Incident Study on Adverse Events in Hospitals Among Medicare Beneficiaries, is the first truly national adverse-event study in the nation documenting hospital-based adverse events among Medicare beneficiaries.1
Previous studies assessing errors and adverse events had tracked the number of events reported, but they had no denominator; in other words, one hospital might have 1,000 reports of adverse events and errors in a given month, while another might have 50, but there was no way to know how many adverse events had been missed and how much harm had actually occurred.
The OIG study dug deeper, conducting in-depth, yearlong reviews led by independent physicians to first identify the rates of harm, then returning to the hospitals in the study where they knew harm had occurred to find out if it had been reported or not.
Overall, the inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. Perhaps one of the most surprising findings was that even some of the most serious, egregious adverse events were not reported. Of the 12 deaths in the sample that were iatrogenic, only two were reported as errors. More serious errors were no more likely to be captured as errors than mild reactions, such as breaking out in hives as the result of a medication.
Why aren’t more hospital-based errors and adverse events being reported, and how can this situation be changed? The OIG’s report provides some insight into the underlying problem: The dominant reason that events weren’t reported was that they weren’t perceived as adverse events. (Not all adverse events are medical errors: A medical error is a preventable adverse event.) A urinary catheter infection, while not necessarily a medical error, is always an adverse event—and yet, only one of the 17 urinary catheter infections identified by doctors in medical review was reported.
Lack of recognition—seeing adverse events and errors as just part of routine care—is only one part of the problem, says Rosemary Gibson, MSc, a former senior program officer at the Robert Wood Johnson Foundation and author of “The Treatment Trap” and “Wall of Silence.” Other issues include: