Nursing Notes

January 8, 2012

Most in-hospital adverse events unreported: OIG

Here is an article from  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

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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October 1, 2009

Too much expected of too few nurses (2007)

Here is an article written in 2007 by Kevin T. Kavanagh, MD. It appears that staffing ratios have long been an issue and actually may be contributing to the current nursing shortage. Please go on to read the entire article because he talks in specifics about how increased patient load adversely affects nurses’ ability to protect their patients. He also talks about the law in Kentucky for reporting suspected cases of abuse, neglect or exploitation of adults or children to the Department of Community Based Services. He explains why this is not always done in the best interest of the nurse, doctor or social worker due to the ability for retaliation against them.

If this situation has been known and allowed to continue since before 2007, that really does say something about the power and clout the hospital lobbyists must carry.

Health Watch USA
Promoting Healthcare Quality, Access & Affordability
No one should ever underestimate the importance of registered nurses. With-out them, there could be no hospitals or nursing homes. The existence of these facilities is solely to provide nursing care. Home health agencies, surgery centers, imaging centers and urgent treatment centers can do the rest.
“How well we are cared for by nurses affects our health, and sometimes can be a matter of life and death,” said an Institute of Medicine report which estimated in 2002 as many as 98,000 patients die each year from medical errors. The National Consumer League reported (2004) that almost half of patients or patient families believed patient care was compromised to some extent by hospital staffing with too few nurses. Twelve percent believed the care was very or ex-tremely compromised.

Aiken reported in the Journal of the American Medical Association found that as a nurse’s patient load doubled from four to eight, the chance of patient death increased 31 percent, and Leape (JAMA, 1995) also reported that nurses were responsible for 86 percent of all interceptions of medical errors.
I would bet errors are more likely caught by a nurse responsible for four to six patients than one trying desperately to take care of eight to 10 patients.

In 2002, low nurse staffing levels were a factor in 24% of all sentinel events which resulted in death, injury or permanent loss of function, according to the Joint Commission (JCAHO), the largest agency which accredits hospitals and guards patient safety . Care the Joint Commission said, “is literally being left undone.” Despite the Joint Commission’s landmark study on the importance of adequate nurse staffing to insure patient safety, the Commission’s ability to assure a high standard of care in hospitals is now questioned.

On June 15, 2006, the American Nursing Association filed suit against the US Department of Health and Human Services for the failure to assure adequate nursing staffing in hospitals. The suit alleges that the Joint Commission’s “nursing standards are totally devoid of standards and requirements concerning the immediate availability of a registered nurse to render bedside care to the patients.” Because of the breakdown of the medical quality assurance, California became the first state to mandate minimum nurse to patient staffing ratios. General medical and surgical floors must have a ratio of 1 to 5 or greater and intensive care units a ratio of 1 to 2 or greater.

With the advent of adequate nurse staffing, the California Nurses Association reported that the California nursing shortage disappeared with a 60% increase in registered nurse licensure applications and a 20% increase in actively licensed registered nurses.>>read more here