Few adverse events reported to states, inspector general says
Twenty-six states had adverse-event reporting systems in 2008, but hospitals reported few adverse events to the state systems, HHS’ inspector general’s office said in a report. The report, dated July 19, attributed the low reporting to hospitals’ failure to identify adverse events rather than from neglect in reporting the events. “CMS, states, and other stakeholders should be aware of this low rate of reporting to state systems as they consider strategies to reduce adverse events in hospitals,” according to HHS’ inspector general’s office. A previous report released by the inspector general’s office found that 27% of Medicare beneficiaries hospitalized in October 2008 experienced serious adverse events, such as prolonged hospitalization, or temporary harm events. About 60% of adverse and temporary-harm events occurred at hospitals in the 26 states with adverse-event reporting systems in 2008. Only about 12% of the adverse events met state reporting systems’ requirements. Hospitals reported only 1% of the adverse events. “This suggests that the low rate of reporting to state adverse-event reporting systems is due largely to hospital staff not identifying incidents of harm as reportable events,” the inspector general’s office said in the report. Also of note, half of the events reported to states that year occurred in Pennsylvania, which requires reporting of all events regardless of severity.