The OIG has issued a report entitled “Adverse Events in Hospitals: Medicare’s Responses to Alleged Serious Events.” The report assesses the responses of CMS, state survey and certification agencies, and hospitals to complaints alleging serious adverse events. The OIG concludes that Medicare’s hospital oversight system missed opportunities to address patient safety in response to alleged serious adverse events (e.g., medication and surgical errors, physical abuse by hospital staff, and patient suicide). For instance, according to the OIG, state survey agencies and CMS: often failed to review hospitals’ compliance with Medicare conditions of participation (CoPs) regarding quality assessment and performance improvement (QAPI) and regarding the hospital’s governing body; performed little longer term-monitoring to verify that hospitals’ corrective actions resulted in sustained improvements; and sometimes failed to disclose the nature of the complaints to the hospitals. In addition, CMS informed the Joint Commission of few complaints, which the OIG believes impeded the Joint Commission’s oversight of its accredited hospitals. Hospitals investigated most complaints in the OIG’s sample, with hospitals beginning two-thirds of their investigations before state agencies conducted their onsite complaint surveys, and hospitals took corrective actions in response to each of 64 complaints. The OIG recommended that CMS: (1) require that all Immediate Jeopardy complaint surveys evaluate compliance with the QAPI CoP, (2) ensure that state agencies monitor hospitals’ corrective actions for sustained improvements, (3) amend guidance on disclosure to explain the nature of complaints to hospitals to allow hospitals to analyze and learn from alleged adverse events; and (4) improve communication with accreditors. CMS concurred with the OIG’s recommendations.