Nursing Notes

January 8, 2012

Most in-hospital adverse events unreported: OIG

Here is an article from ModernHealthcare.com  that addresses the failure to report events causing patient

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harm.  The article goes on to point out reasons for such a failure and the reasoning does make sense.  However, I feel quite strongly that if nurses had the time to make reports and if those reports were simple and easy, there would be quite a few made.  As it is, nurses are drowning in patient loads, paperwork, and have little to no time to eat or use the restroom, so forgive me if we sometimes don’t stay after our shift to enter cumbersome reports into the computer about events that really did not cause harm but could have.

Please read this article and I would love to hear your take on this topic.

____________________________________________________________________________

By Maureen McKinney

Posted: January 6, 2012 – 4:00 pm ET
Read more: Most in-hospital adverse events unreported: OIG – Healthcare business news and research | Modern Healthcare http://www.modernhealthcare.com/article/20120106/NEWS/301069970#ixzz1isnhQ09U
?trk=tynt

The vast majority of in-hospital adverse events go unreported by staff, according to a report from HHS’ inspector general’s office (PDF).

Using a month of survey data from a sample of 189 hospitals, the inspector general’s office found that hospitals’ voluntary incident reporting systems captured only about 14% of events that cause patient harm, such as medication errors. Federal investigators attributed low reporting rates, at least in part, to poor knowledge among hospital staff about what patient harm actually means.

“For example, staff reported only one of 17 sample events related to catheter usage (e.g., infection and urinary retention), a common cause of harm to Medicare beneficiaries,” according to the report.Other types of events that went unreported included cases of excessive bleeding related to misuse of blood thinning medications, and hospital-acquired infections.Incident reporting systems are a requirement for participation in Medicare, but a lack of uniform requirements—such as lists staff can use to identify patient harms—can damage the systems’ reliability, according to the report.“Because hospitals rely on incident reporting systems to track and analyze events, improving the usefulness of these systems is critical to hospitals’ efforts to improve patient safety,” the report said.

The report urged the CMS and HHS’ Agency for Healthcare Research and Quality to develop a list of adverse events for hospitals to use. Additionally, the office said, the CMS should reassess its methods for judging hospital compliance with the reporting-system requirement.

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2 Comments »

  1. I totally agree. And I would add that adverse events happen in the chiropractic profession as well. Since most chiropractors work alone, there is not the same oversight like there is at a hospital. Although I have never broken ribs, I know chiropractors who have. I think the most common adverse event is local tenderness or local joint irritation. It seems that adverse event that gets the most press is stroke. But stroke is incredibly rare. They happen, but very rare. I’d like to see some more transparency in the profession and report even the minor injuries.

    Comment by Dr. Andrew White — January 24, 2012 @ 11:18 pm | Reply

  2. Hi ,
    I can’t seem to be able to find your contact form/email.
    Would you be interested in a guest post for you blog? If you’re interested get back to me at my email.

    Best Regards,
    Catherine Santos

    Comment by Catherine Santos — January 27, 2012 @ 1:18 am | Reply


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