When inspectors investigate serious never events at hospitals, they need to do a better job focusing on overall patient-care quality issues and then disclosing to hospitals and accreditation agencies exactly what occurred, an audit from the HHS inspector general's office has found (PDF).

The report follows a 2008 inspector general's study that estimated as many as 25% of all Medicare beneficiaries were harmed during hospital stays in October of that year, including 13% that involved a prolonged hospital stay, permanent harm, life-sustaining intervention or death.

On Tuesday, the inspector general released the results of an intensive study of 95 incidents that resulted in “immediate jeopardy” complaints being filed against hospitals; immediate-jeopardy complaints are the most serious events and require inspections within two days. The five most common types of immediate jeopardy never-events were sexual assaults, medication errors, physical abuse by staff, restraint problems and suicide.

Auditors found that fewer than half of the inspections that were ordered included a review of Medicare's conditions of participation that require quality-monitoring programs, even though Medicare officials say quality-improvement is central to patient safety.

Auditors recommended that inspections for all immediate jeopardy complaints be limited to the discrete incident and the hospital's quality-improvement program, which should be self-regulating. “Central to this (condition of participation) is the idea that the hospital should take responsibility for improving its performance rather than relying on the survey process and the threat of punitive actions,” inspector general auditors wrote.

The inspector general's office noted that state inspectors sometimes withheld information about the complaint being investigated, which could have prevented hospitals from taking action. The auditors also said accreditation experts with the Joint Commission received notice of only eight of the 88 incidents that took place at hospitals it accredited.

A response from the CMS said the agency will increase the prominence of quality conditions of participation in its inspections following immediate-jeopardy complaints and explore ways to improve its communications with accrediting agencies following inspections.