An Office of Inspector General's report last week again poked holes in the credibility of the nation's hospital patient harm reporting system. After analyzing clinical records for Medicare beneficiaries treated by 189 hospitals, the agency determined those hospitals had reported only 1% of adverse events.
Four sentences of this report are of particular interest:
1. "To date, no Federal standards require States to operate adverse event reporting systems."
2. Half the states do not operate adverse event reporting systems to monitor the occurrence of harmful events in hospitals.
3. The 25 states and the District of Columbia that do have reporting standards "varied as to whether they made reporting voluntary or mandatory, what types of events they specified should be reported, and what additional information they asked hospitals to report."
4. "Hospital administrators indicated that staff often did not report events because they identified them not as patient harm, but rather as expected side effects."