Adverse Events in Hospitals Not Being Reported

As an attorney who represents injured patients and their families in medical malpractice cases, patient safety is always a concern. One crucial way that patient safety is improved in hospitals is for the hospital to be aware of all adverse events that occur within its walls. While there is no universally agreed-upon definition of what constitutes an “adverse event,” it is usually considered to be an unfavorable or unintended consequence of some form of medical treatment or drug. An adverse event does not mean anyone was at fault in causing it, and the resulting harm may be mild, moderate or severe. Regardless of the definition, doctors and nurses have an obligation to report adverse events so that the events can be evaluated and so that changes can be made to improve patient safety. However, it appears that most of the time, such adverse events are not being reported.

As reported by American Medical News, the Department of Health and Human Services Office of Inspector General (“OIG”) conducted a study on the reporting of adverse events. Amazingly, the “OIG’s study found that 86% of harmful inpatient adverse events are not captured by hospitals’ incident-reporting systems…” An earlier study in April 2010 by Health Affairs (cited by the OIG study) had even grimmer news. In a review of 795 patient records at three hospitals, they found 354 instances of patient harm that required some measure of medical treatment to address. Only four of these incidents were captured by the hospital’s reporting systems. The study found that there were even four patient deaths that went unreported. If this many unreported events were found at just three hospitals, it is sobering to consider how many that must go unreported in all of the hospitals located in the Baltimore area.

The OIG study tries to explain why adverse events are not being reported. Health care workers cited various explanations for why events were not reported, including that the event was not caused by a perceptible error, that the event only caused little harm, that the event was an expected side effect or outcome, and other explanations. One remedy the OIG is recommending is the creation of a master list of reportable events so that health care workers know exactly what type of events need to be reported. While that may help in ensuring accurate reporting, the obligation still rests with each health care provider to report all adverse events so that patient safety can be improved.