You might expect that if a surgeon, nurse or other health care worker at a hospital makes an error, it would be reported, both to inform hospital managers and to avoid making the same error twice. But according to a study by the health inspector general of the U.S. Department of Health and Human Services, hospitals recognize and report only one out of seven errors, accidents and other events that harm hospitalized Medicare patients. Such events often lead to medical malpractice lawsuits, and could lead to more if they aren’t caught the first time they happen.
As a condition of being paid under Medicare, hospitals are supposed to track medical errors and adverse patient reactions, analyze their cause, and improve care as a result. Most hospitals do have a system for employees to report these errors and their results to hospital managers. But according to the study, hospital staffs didn’t report most of the events that harmed Medicare beneficiaries, including some that caused patient deaths.
Just how many errors are we talking about? The report estimated that more than 130,000 Medicare patients experienced one or more adverse events in a single month. These events included medication errors, severe bedsores, infections, delirium from overuse of painkillers and excessive bleeding from improper use of blood thinners.
Some hospital administrators did acknowledge that workers were underreporting problems. A national report on patient safety in 1999 found that hospital employees were often afraid to admit mistakes. But these days, the new report suggests, the problem is that employees don’t recognize what constitutes harm or that some events even harmed patients and should be reported. In some cases, employees simply assumed someone else would report the error, or that it was so common it didn’t need reporting. In response, Medicare officials have promised to develop a list of “reportable events” that hospitals could use.
A further problem the study found was that even after hospitals investigate preventable errors, they rarely change their practices. Some hospital executives told investigators that the negative events didn’t reveal any “systemic quality problems.”
Although more hospitals are pledging to report medical errors, Medicare beneficiaries and other patients still run the risk of being harmed from an error that could have been prevented through earlier reporting. Those who have been harmed could benefit from consulting with an attorney experienced in medical malpractice. Even if the hospital doesn’t report a mistake in your care, you can.
Source: New York Times, “Report Finds Most Errors at Hospitals Go Unreported,” Robert Pear, Jan. 6, 2012