Hospitals' Adverse Event Reporting Systems Inadequate

Cheryl Clark, for HealthLeaders Media , July 26, 2012

Even though every hospital is required by its Medicare/Medicaid contract to have an internal adverse event reporting system—the existence of which is verified by accreditation agencies such as the Joint Commission—only 14% of adverse events experienced by beneficiaries were recognized as such internally, the OIG report said.  Instead, they were seen as expected complications.

Classen advocates a federal system in which all hospitals are required to be transparent about all patient harm in a uniform way. And only when all those events are quantified and examined can the healthcare system prioritize which should be targeted first. Electronic health records, he says, can not only sound an alert when a potentially harmful event is about to occur, but retrospectively provide clues as to what led to it.

He notes that the septic shock death of Rory Staunton, the 12-year-old boy who died after he was mistakenly sent home from the emergency room of NYU Langone Medical Center with dangerously high levels of white blood cells and a fever, might have been prevented with such a warning system.

He adds that today, many hospital leaders are stuck in a mindset of thinking that very few harmful events are preventable. "The problem with deciding rigidly what is preventable and what is not is that over time, we've seen how preventability is a moving target," Classen explains.

For example, "We used to say that only one-third of hospital infections were preventable, but now, most people would agree that 75% to 80% are preventable. Ultimately, as we get smarter about this, we'll see that a lot more of it will be preventable, and even if we can't prevent it, it helps to identify it early and mitigate it."

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1 comments on "Hospitals' Adverse Event Reporting Systems Inadequate"

Cynthia Jones, COHQ (7/26/2012 at 2:47 PM)
Regardless of a national standard and nomenclature - hospitals have the responsibility to First-do no harm. With that, humans make errors, and we are human. Health systems must facilitate a culture of safety to first - idenitfy, report and address actual harm with prevenatative strategies and system improvements. That is still a huge gap even in the "best centers". From that- organizations begin to learn to identify weaknesses in processes and do proactive strategies based on Near Misses... It's every healthcare members responsibility... It's about building and establishing fundamentals of safe care: Communication, Validation, and thorough assessment that utilze the bedside experts in care-who know processes and their variables - to build better care. It's not the Board, or The CEO, or The Managers, or The Staff. It's AND -all working for the same cause. It's culture. It's fundamental. It can be done.




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