High rate of unreported adverse events not surprising: safety experts
High rate of unreported adverse events called unsurprising by experts
Patient-safety experts say they’re not surprised or even particularly alarmed by a seemingly troubling finding that hospitals’ voluntary reporting systems capture few adverse events. “It’s well-known in the safety world that voluntary reporting systems are neither accurate nor can be because people tend not to see the errors around them as they become normalized,” Dr. Donald Berwick, former CMS administrator, said in an interview.
Hospital incident-reporting systems captured only 14% of adverse events, such as medication errors and falls, leaving 86% of events unreported by staff, HHS’ inspector general’s office con- cluded in a report released Jan. 6. Such reporting systems are a condition of participation for the government’s Medicare program, but hospitals’ reporting requirements and definitions of patient harm are often unclear to employees, HHS’ inspector general’s office said in the report.
“For example, staff reported only one of 17 sample events related to catheter usage (e.g., infection and urinary retention), a common cause of harm to Medicare beneficiaries,” the report said.
Other types of events that went unreported included aspiration, pressure ulcers and allergic reactions.
Incident-reporting systems do serve an important purpose in hospitals, Berwick said, but he argued that they should be viewed as a cultural asset that promotes teamwork and transparency instead of a statistical tool.
“Understand that even in the most developed safety culture, voluntary reporting is going to be a weak tool for measurement,” Berwick added. “It’s never going to be a mainstay.”
Other methods show much more promise for reliably measuring adverse events, Berwick said, including the Institute for Healthcare Improvement’s Global Trigger Tool, which uses chart review to identify incidents of patient harm. And further adoption of electronic health records will bring other measurement tools that are even easier to use, he said.
“In order to make healthcare safe, there has to be a whole suite of activities to encourage identification of patient injuries,” Berwick said.
While the inspector general’s report does illustrate incident-reporting systems’ low capture rate, it’s also useful because it lists the types of events that staff most often failed to recognize as patient harm, Berwick said. He pointed to several categories of adverse events that ranked among the least reported by staff, including IV fluid overload, excessive bleeding and delirium.
Only seven out of 29, or 24%, of delirium events were captured during the study period. And staff only reported two of 15 inci-
dents involving excessive bleeding. Those are good places for hospitals to focus quality improvement efforts, Berwick said.
Margaret Vanamringe, vice president for public policy and government relations for the Oakbrook Terrace, Ill.-based Joint Commission, praised the inspector general’s recent series of reports focused on adverse events, including one released in October 2011 that examined the way the CMS responds to alleged serious patient-harm events.
But Vanamringe did express concern about the data in this latest report. The inspector general’s office used survey data from a sample of 189 hospitals about events captured in October 2008.
“A lot has happened since then,” she said, citing less punitive environments in many organizations and a greater push toward reporting by the government and groups such as the Joint Commission. “Staff in hospitals are now seeing the value of reporting these events.”
Hospitals can use the data in the inspector general’s report to identify ways to improve their own incident reporting systems, said Nancy Foster, vice president of quality and patient-safety policy for the American Hospital Association. Foster acknowledged that many types of events, such as near misses, are difficult for staff to recognize and consistently capture in the system.
“Sometimes people don’t report things because they see them as natural occurrences in the hospital,” Foster said. That requires education and guidance from management, she added. “Helping employees of all kinds to see how the information will be used is the most effective strategy to encourage them to report more.”
But boosting employees’ reporting rates may be the wrong direction to go in, said Dr. Robert Wachter, patient-safety advocate and professor and chief of the division of hospital medicine at the University of California at San Francisco.
“What worries me is not the 14%,” he said, referring to the capture rate cited in the report. “My worry is that number will prompt more incident reporting and I’m not sure that’s a good idea.”
In a 2009 blog post titled “Hospital incident reporting systems: Time to slay the beast,” Wachter argued that such systems are a drain on clinicians’ time and goodwill. Not much has changed since then, he said.
“There are so many types of harm and errors that relying on voluntary reporting by frontline caregivers is simply not the right way,” Wachter said. Incident-reporting systems are necessary, he continued, but they can be burdensome and should be limited to a very narrow list of serious events. For gauging other types of patient harm, Wachter says trigger tools are effective, as are EHRS, increasingly.
“I have no objections to requiring hospitals to have incident-reporting systems in place,” Wachter said. “Let’s not throw the baby out with the bathwater, but we have to be much more thoughtful about them and that means paying more attention to the time and energy of caregivers. Asking a nurse to take 15 minutes to report every event does more harm than good and can really contaminate the way she thinks about the patient-safety agenda. ”
Some patient-safety experts say it’s too burdensome to ask frontline caregivers to report a wide array of adverse events.