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."
But, Classen explains, those 28 "are rare, orders-of-magnitude less-common than other adverse events that occur in hospitals, such as side effects of drugs, or complications from procedures or infections. That's where the money is. But unfortunately, these reporting systems don't address those."
To date, hospital reporting systems don't routinely pick up, for example, harmful urinary tract infections that can lead to sepsis and patient death, especially in a patient who is frail.
Adverse Event or 'Expected Complication'?
Classen explains: "the hospital administrator will say, 'Oh, that's not an adverse event; that's an expected complication.' Well, my comment back is, 'No. If you had used the catheter properly, you could have gotten it out quickly and this wouldn't have happened.' "
Apparently, many hospitals today just put these events into the category of "Sometimes Bad Stuff Just Happens,"or chalk it up to the natural deterioration of the patient's condition. There's no event report, internal or external.