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Hospital Incident Reporting Systems Do Not Capture Most Patient Harm

Hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries. Hospitals investigated those reported events that they considered most likely to lead to quality and safety improvements and made few policy or practice changes as a result of reported events. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent).

As a condition of participation in the Medicare program, Federal regulations require that hospitals develop and maintain a Quality Assessment and Performance Improvement (QAPI) program. To satisfy QAPI requirements, hospitals must "track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital." To standardize hospital event reporting, AHRQ developed a set of event definitions and incident reporting tools known as the Common Formats. We requested and reviewed incident reports from hospitals regarding patient harm events. We had previously identified these events from a nationally representative sample of Medicare beneficiaries discharged in October 2008.

All of the hospitals we reviewed had incident reporting systems designed to capture events; hospital administrators we interviewed indicated that they rely heavily on the systems to identify problems. Hospital accreditors reported that they do not investigate event collection methods, such as incident reporting systems, unless evidence of a problem emerges through the survey process.

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.

Therefore, we recommend that AHRQ and CMS collaborate to create and promote a list of potentially reportable events for hospitals to use. We further recommend that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events. CMS should also suggest that surveyors evaluate the information collected by hospitals using AHRQ's Common Formats. Additionally, CMS should scrutinize survey standards for assessing hospital compliance with the requirement to track and analyze events and reinforce assessment of incident reporting systems as a key tool to improve event tracking.

We received comments on the draft report from AHRQ and CMS. AHRQ concurred with our recommendation, stating that it will collaborate with CMS to create a list of potentially reportable events and provide technical assistance to hospitals in using the list. CMS also concurred with our recommendations, stating that strengthening hospital reporting systems and practices is an essential component of efforts to prevent patient harm. CMS stated that a voluntary list of adverse events used for informational purposes could be highly beneficial for improving incident reporting practices. CMS also stated that it is developing draft guidance for surveyors regarding assessment of patient safety improvement efforts within hospitals.