Spotlight On... Adverse Events (Patients admitted to the hospital generally expect that the medical care they receive will improve their health, not worsen it. Unfortunately, that isn't always the case.)

[Oliver Crangle]

Spotlight On... Adverse Events


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Podcast: Adverse Events in Hospitals Available in English and español.
Patients admitted to the hospital generally expect that the medical
care they receive will improve their health, not worsen it.
Unfortunately, that isn't always the case. In some instances, patients
are harmed as a result of their medical treatment. For example, a
patient may contract an infection associated with the use of a
catheter or experience a surgical complication. According to an OIG
report, these types of events - termed "adverse events" - affect a
significant portion of Medicare beneficiaries.
More Than One in Four Medicare Beneficiaries Experience Some Degree of
Harm While Hospitalized
Types of Events
Adverse Event - An event, preventable or nonpreventable, that caused
harm to a patient as a result of medical care. This includes never
events; hospital-acquired conditions; events that required life-
sustaining intervention; and events that caused prolonged hospital
stays, permanent harm, or death.
Never Event - A serious event, such as surgery on the wrong patient,
that the National Quality Forum included on a specific list of events
that "should never occur in a health care setting."
Temporary Harm Event - An event that requires intervention but does
not cause lasting harm, such as an allergic reaction or hypoglycemia.
Prompted by the Tax Relief and Health Care Act of 2006, OIG conducted
a thorough examination of the issue of adverse events. Perhaps the
most noteworthy outcome is a report describing the incidence rate of
these events. Though others have attempted this challenging task
previously, estimates of this rate varied widely. Using a random
sample of Medicare beneficiaries discharged from hospitals during a 1-
month period, OIG found that 13.5 percent experienced adverse events
and that for 1.5 percent of beneficiaries, these adverse events
contributed to their deaths. An additional 13.5 percent of
beneficiaries in the sample experienced temporary harm as a result of
their medical care, bringing the total percentage of beneficiaries
experiencing instances of care-related harm to 27 percent. Nearly half
(44 percent) of these adverse or temporary harm events were
preventable.
While these statistics are troubling on their own, the prevalence of
these events has wider impact. OIG determined that the costs to
Medicare associated with adverse and temporary harm events totaled an
estimated $324 million for 1 month alone. This would equate to an
estimated $4.4 billion per year.
In light of these findings, OIG recommended that the Agency for
Healthcare Research and Quality (AHRQ) and the Centers for Medicare &
Medicaid Services (CMS) broaden their patient safety efforts to
include all types of adverse events and advance efforts to identify
these events. In addition, CMS should provide further incentives for
hospitals to reduce the incidence of adverse events.
Reporting Systems To Track Adverse Events Exist but Often Miss Events
and Opportunities for Improvement
Supplementary OIG Work on Adverse Events
To inform its examination of the incidence rate of adverse events, OIG
consulted the landmark Institute of Medicine report,
To Err is Human: Building a Safer Health System , and produced
several preliminary reports discussing both assumptions and known
facts about adverse events in hospitals. OIG also conducted a
preparatory case study of the adverse events that occurred in two
counties. Following the case study, OIG evaluated all the possible
methods for identifying adverse events and discussed them in a
separate report on methodology. OIG's complete body of work on the
topic of adverse events in hospitals is listed below:
Overview of Key Issues
Case Study of Incidence Among Medicare Beneficiaries in Two Selected
Counties
State Reporting Systems
Public Disclosure of Information about Events
Methods for Identifying Events
National Incidence Among Medicare Beneficiaries
Op-Ed: Medical Mistakes Plague Medicare Patients
Medicare's Responses to Alleged Serious Events
Hospital Incident Systems Do Not Capture Most Patient Harm
Few Adverse Events in Hospitals Were Reported to State Adverse Event
Reporting Systems
In addition to studying the frequency of adverse events, OIG examined
adverse event reporting systems. Hospitals are required to track and
analyze patient harm as a requirement of participating in Medicare,
and in fact, all the hospitals in OIG's sample had such a system in
place.
Yet, OIG found that hospital staff did not report 86 percent of events
to incident reporting systems. Previous explanations for low
reporting levels include the following: (1) staff do not have time,
(2) staff fear punitive action, and (3) staff do not believe that
reports will lead to improvement. However, this report found that the
low level of reporting is also due partly to hospital staffs' lack of
understanding as to what constitutes patient harm. Therefore, OIG
recommended that AHRQ and CMS develop a list of potentially reportable
events to assist hospital staff.
In addition, there is no comprehensive national reporting system for
adverse events, and only half of States have systems. These State
reporting systems vary greatly, with differences in what constitutes
an adverse event, what information must be recorded, how that
information is used, and whether information about the event is
publicly disclosed. Across the board, however, OIG found that States
with systems often require reporting for only a small subset of
events. Just 12 percent of the temporary harm or adverse events that
occurred in hospitals met State requirements for reporting; in other
words, only 35 of the events in the sample were required to be
reported to the State reporting systems. Hospitals actually reported
just three of these events, all in Pennsylvania. Many of the events
not reported as required involved serious harm, including six patient
deaths.
Finally, another OIG report found that when the Medicare program
receives reports of alleged serious adverse events, it often misses
opportunities to promote patient safety in its responses. More
detailed information can be found in the report.
OIG Will Continue To Examine Adverse Events
OIG plans to continue exploring the complex yet vitally important
issue of adverse events, looking beyond hospitals to other medical
settings. One study underway is examining the frequency of adverse
events in nursing homes, the factors that contributed to those events,
and their costs to Medicare.



https://oig.hhs.gov/newsroom/spotlight/2012/adverse.asp