Billing data may not be a reliable source of hospital adverse event information and voluntary hospital incident reporting systems may be an unreliable source of information for patient-safety organizations, according to Adverse Events in Hospitals: Methods for Identifying Events, a new report released by the HHS inspector general's office.
HHS researchers reviewed a random sample of 278 Medicare beneficiary hospitalizations in acute-care hospitals in two unidentified counties that took place during one week in August 2008. The researchers found that hospitals did not produce internal incident reports in 93% of 120 events where patient harm occurred in the hospital or as a result of care.
It was also found that diagnosis codes were absent or inaccurate in the billing data for seven of the 11 identified cases of hospital-acquired conditions. The CMS, according to the report, responded by indicating that it has “established a process for providing coding advice to hospitals” and that it will perform its own study of the accuracy of coding for hospital-acquired conditions.
“The high number of incidents is shocking,” said Helen Haskell, founder of Mothers Against Medical Error, a patient-safety advocacy group. “It is even more shocking that so many of them are unreported or incorrectly recorded. This is the problem of self-reporting in a nutshell. This should be a wake-up call. We have become inured to a high level of harm in a field that is supposed to provide relief from harm, and we have developed a culture that does not take responsibility for its actions.”