Hospitals Reported Few Captured Patient Harm Events to CMS and States

Why OIG Did This Review

External reporting of patient harm is a crucial component in addressing patient safety. Hospitals are required to report certain types of harm events to meet CMS program and State legal requirements. External reporting holds hospitals accountable for harm events and is intended to promote awareness and encourage learning from such events. Prior OIG work found that hospitals reported few harm events to State reporting systems. We revisited this issue while conducting a study on hospitals’ identification and response to patient harm events. The full results of the study are described in the report Hospitals Did Not Capture Half of Patient Harm Events, Limiting Information Needed to Make Care Safer (OEI-06-18-00401), which is being issued concurrently with this memorandum report.

What OIG Found

Our results show a significant discrepancy between the events that CMS and States expected hospitals to report and the events that hospitals actually reported. Nationwide, we determined that 16 percent (15 of 94) of harm events that hospitals identified and captured in their incident reporting or other surveillance systems were required to be reported externally per CMS and/or State requirements. Yet, in our sample, hospitals reported only 5 of 15 captured events per these requirements. For the remaining 79 events not required to be reported externally, hospitals voluntarily reported 7 of those events for learning purposes.

What OIG Concludes

Hospitals reported few patient harm events to CMS and States, thereby limiting hospital transparency and accountability for harm that occurred in their facilities. When hospitals fail to identify and report harm events to the appropriate oversight entities, they stymie independent feedback needed to take corrective actions. The lack of such actions hampers system level improvements that can prevent future harm from occurring. We urge CMS, States, and other groups (e.g., accreditation organizations and other Federal agencies) to weigh these results as they develop new strategies to improve patient safety. These results also support the recommendations made in our companion report.