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Incidence of Adverse Events in Indian Health Service Hospitals


OIG conducted this review to estimate the incidence of adverse events and temporary harm events in IHS hospitals and to assess the extent to which these events were preventable. Adverse events and temporary harm events, also referred to as patient harm events, indicate that a patients' care resulted in an undesirable clinical outcome not caused by underlying disease. IHS provides comprehensive Federal health services to approximately 2.6 million American Indians and Alaska Natives—a medically vulnerable population with poorer health outcomes and barriers to accessing health care. Prior OIG reports have identified longstanding challenges to IHS's ability to deliver safe and high-quality health care to American Indians and Alaska Natives. Challenges faced by IHS hospitals include staffing shortages and lack of specialty care, with the agency's Great Plains Area being a location of particular concern. This report is part of an OIG series of reports about adverse events in health care settings and continues OIG's commitment to monitoring the quality of care at IHS facilities.


We selected a stratified random sample of 400 patients, from pediatric patients to older adults, who had at least one admission to an IHS hospital during fiscal year (FY) 2017. Our final sample consisted of 384 patients because of ineligible admissions and missing medical records. We calculated the incidence rate of patient harm events in IHS hospitals from a review of patients' medical records. We conducted the review in two stages. In the first stage, nurses screened the records for possible patient harm events using a "trigger tool method." A "trigger" is a clinical clue—for example, documentation of a fall—that may indicate harm. In the second stage, physician-reviewers conducted a full review of the medical records flagged by nurses as containing possible harm events. Physician-reviewers identified harm events and assessed the level of harm, whether events were preventable, and factors that contributed to events.


An estimated 13 percent of patients in IHS hospitals experienced patient harm events during their stays in FY 2017. We found a higher rate of harm in smaller IHS hospitals (those with fewer than 1,000 admissions in FY 2017). Most patient harm events we identified were temporary harm events, and more than half of patient harm events were related to the use of medication. In our sample, patient harm events were more prevalent among older adults (65 and older) and labor and delivery patients (any age), whereas pediatric patients (up to and including 17 years of age) had very few harm events. An estimated 7 percent of patients overall—slightly over half of the 13 percent of patients who experienced harm events—experienced events that were preventable, i.e., they could have been prevented if the patients had been given better care.


In an effort to reduce patient harm, OIG recommends that IHS's Office of Quality establish patient harm monitoring and reduction as a key priority. IHS should also use an improved and fully implemented incident reporting system to effectively track and monitor patient harm events. We further recommend that IHS implement quality improvement plans to improve patient safety across IHS, including plans that specifically focus on smaller hospitals and patient groups at higher risk of harm. IHS concurred with our recommendations and affirmed that patient safety is a high priority for the agency. Actions reported by IHS included enhanced partnerships, such as with the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality, further hospital adoption of quality improvement and compliance plans, and implementation in 2020 of its new incident reporting system, I-STAR, across all IHS Areas and facilities.