A new report released last month by the inspector general of the U.S. Department of Health and Human Services found that more than 80 percent of hospital errors go unreported by hospital employees. That means only 1 out of 7 medical errors and accidents that harm Medicare patients are reported by hospital employees.
The report looked at data from hospitalized Medicare patients since hospitals are required to report these errors as a condition of being paid under Medicare. However, it has been shown that the organizations that inspect these hospitals only loosely regulate the hospital tracking records. The study showed that even when errors are reported and after medical facilities investigate the reported injuries or infections, the facilities rarely change any practice to prevent it from happening again.
It was indicated in the report that hospital administrators knew their employees were not reporting these adverse events. Nearly all hospitals have some type of system for employees to inform hospital managers of adverse events, defined as significant harm experienced by patients as a result of medical care. However, even with these systems in place, most medical errors are not being reported.
The study attributes this occurrence to the fact that many hospital employees may not recognize what constitutes patient harm, or they may not realize that particular events harmed patients and should be reported. It seems that the majority of the cases that go unreported are not perceived as errors by hospital staff. Other cases that went unreported were found to be situations that were typically reported by the staff but happened not to be reported.
The errors that went unreported included overused or wrong medications, severe bedsores, hospital-based infections, and even patient death. The more serious events, like hospital-acquired infections and patient deaths, were no more likely to be reported than the smaller cases, like allergic reactions to medications.
The best way to prevent these types of errors is through education. All hospital employees must be trained to recognize these events and to report them. Some employees do not recognize some medical errors as “errors” because they are so common. This type of thinking needs to be changed and higher standards need to be upheld. Employees should not be scared to come forward and report errors, saving a person’s life should be the number one goal.
Hospital administrators should also take some responsibility and find new ways to ensure errors are reported and managed. Changing policies and creating new ones to meet the new goals seems to be an obvious place to start. The fact that only a few errors were reported in this study and none of them caused any change is disturbing. It is also important that agencies that are supposed to be monitoring the report of errors are not getting slack with their standards either.
Finally, patients themselves can try to educate themselves and be prepared when they or a family member are going to be in the hospital. Knowing what to expect and what to look for could save a lot of heartaches.
