In a report released July 19, 2012, by the Department of Health and Human Services Office of Inspector General (OIG), OIG found that hospitals are under-reporting adverse events to State authorities. OIG found that approximately 60 percent of adverse events nationwide occurred in States with reporting systems, 12 percent of events met State requirements for reporting, and hospitals reported only 1 percent of events. Notably, most of the reportable events that hospitals failed to report had not been identified by internal hospital incident reporting systems, suggesting that the under-reporting problem stems from a failure to identify reportable events rather than from a failure to report known events.
State reporting requirements were surveyed in a 2008 OIG report, Adverse Events in Hospitals: State Reporting Systems (OEI-06-07-00471), available by clicking here, which found that 25 States plus the District of Columbia maintained adverse event reporting systems, but that the State systems varied as to whether reporting was voluntary or mandatory and as to what types of events and information must be reported. According to the 2008 report, 3 states use the National Quality Forum List of Serious Reportable Events and 23 states have their own lists, which vary greatly.
Earlier this year, OIG published a related report (OEI-06-09-00091) in which it evaluated the efficacy of hospital incident reporting systems, concluding that by and large, these systems fail to capture most patient harm events affecting Medicare beneficiaries. This earlier report is discussed in a Health Headlines article published in the January 9, 2012 edition, available by clicking here.
The most recent OIG report, Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems (OEI-06-09-00092), is available by clicking here. Additional OIG resources pertaining to adverse event reporting are available on the OIG’s website.