As required by the Tax Relief and Health Care Act of 2006, the Office of Inspector General (OIG) of the Department of Health and Human Services has issued a report entitled “Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries” (OEI-06-09-00090). Although the statute requires that OIG report on the incidence of “never events”—a list of serious events, e.g. surgery on the wrong patient, that “should never occur in a health care setting,” according to the National Quality Forum—in its most recent report the OIG analyzed adverse events of varying degrees of seriousness. In particular, the OIG attempted to estimate the incidence of adverse events for hospitalized Medicare beneficiaries nationwide and to determine the preventability and cost of such events. Using this information, the OIG made a series of recommendations to the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS).

The OIG found that around one in every seven hospitalized Medicare beneficiaries experienced adverse events during their hospital stays. In particular, OIG estimated that 1.5 percent of hospitalized Medicare beneficiaries experienced an adverse event that resulted in death. Another one in seven experienced events that resulted in some degree of temporary harm. The costs associated with these events totaled $324 million in one month alone, representing an estimated 3.5 percent of Medicare’s total expenditure for inpatient care. Of the patients who suffered from either an adverse event or a temporary harm event, more than half suffered an event that could not be prevented, while 44 percent suffered events deemed clearly or likely preventable. Preventable events were linked most commonly to a lack of patient monitoring, substandard care, or medical error.

In order to reduce the incidence of adverse events and to lower the amount of Medicare funds devoted to them, OIG made three recommendations to AHRQ and CMS. First, rather than focusing on a specific list of adverse events, both agencies should broaden their safety efforts to include all types of adverse events. Second, the agencies should improve their mechanisms for identifying the occurrence of adverse events. For example, AHRQ should put in place a specific protocol for identifying and analyzing these events. Meanwhile, CMS should require that Quality Improvement Organizations (QIOs) use Present on Admission (POA) indicators to identify the incidence of adverse events at individual hospitals. Third, CMS should incentivize the reduction of adverse events. For example, CMS should expand the list of hospital-acquired conditions. In addition, CMS should more rigorously enforce the condition of participation in Medicare and Medicaid that requires hospitals to have programs that demonstrate quality improvement.

Both AHRQ and CMS agreed with OIG’s recommendations. AHRQ called the incidence of adverse events “alarming.” CMS responded to the report by stating that it will “aggressively pursue” broadening the scope of its patient safety efforts and incentivizing hospitals to reduce the incidence of adverse effects.

The report is available by clicking here.