In an increasingly alarming trend, many hospitals are failing to capture a significant percentage of patient harm events, according to a report from the Office of Inspector General (OIG), under the Department of Health and Human Services (HHS). This oversight comes as a result of staff misinterpretation, dismissal of potential harm indicators, or rigid reporting guidelines that prioritize specific types of harm.
In July, the OIG revealed that out of 299 harm events traced amongst 770 discharged Medicare patients in October 2018, a staggering 49% went unreported by hospitals. This report emphases on the fact that these events were partly overlooked because staff either did not perceive them as harmful or are not obligated to disclose such events under their current reporting requirements.
Upon a deeper analysis, it was discovered that of the 49% undisclosed harm, 46% of these events were incorrectly classified as known complications or side effects, due to a lack of understanding or misjudgment by the hospital staff. Regrettably, for 16% of these harm instances, the events were not reported simply because they did not align with the hospital’s reporting criteria.
This gap in reporting increases the potential risk for patients, especially when 20% of these overlooked events were found to be challenging to differentiate from the progression of the underlying disease. Additionally, there were circumstances where the harm was attributed to post-discharge complications, which accounted for 4% of the missed occurrences.
Unsurprisingly, procedure-related harm events – including those related to surgeries – accounted for a significant 73% of the total missed harm events. Furthermore, the under-reporting rate was higher in teaching hospitals, with a 62% missed rate in comparison to non-teaching facilities’ 46% rate. This could potentially be due to the higher complexity of cases typically handled in teaching institutions.
Lastly, the OIG’s report highlights a pervasive issue in our healthcare system: the lack of standardized definition for ‘harm events.’ This discrepancy creates inconsistency across hospitals, making it challenging to maintain a reliable nationwide measurement of patient harm cases.
In conclusion, the findings urge for the necessity of standardized reporting guidelines and a comprehensive understanding of ‘harm events.’ Hospitals should take cognizance of this critical issue and work collaboratively to improve patient safety and ensure a decrease in missed harm events in the future.