In other words, the systems by which the nation's hospitals detect and quantify patient harm within their facilities can be summarized with the Tower of Babel cliché: It seems that everyone uses a different definition of what is a reportable adverse event.
David Classen, MD, an infectious disease expert at the University of Utah who developed the Institute for Healthcare Improvement's patient safety Global Trigger Tool and helped write the Institute of Medicine's report "Health IT and Patient Safety," agrees.
Validity of Tracking Questioned
"If you think you can go to your state and look at their adverse reporting events and have any clue what's going on in hospitals, you're smoking some very good stuff," Classen told me in an interview. "The first step is for us to admit that our whole system is tracking nothing valid."
His words may be harsh, but correct, even as they come after a November, 2010 OIG report that found that more than one in four Medicare beneficiaries endured hospital-caused harm. And for half of those, the harm was serious; some patients died. Nearly half of all these events, 44%, were preventable, the OIG said.
Variation in hospital adverse event reporting is a serious problem because it impedes our ability to learn if procedural changes and safeguards are working. But what's even worse is that none of these systems are actually capturing the bulk of adverse events that cause harm.
Even the very best state reporting systems, like Pennsylvania's, "only pick up a teeny, teeny fraction of all these adverse events," Classen says. Instead, they are only picking up very serious events that are obvious, such as wrong-site surgery, or stolen newborns, or retained surgical objects. These are listed in the National Quality Forum's 28 "Serious Reportable Events."