The OIG has issued a report entitled “Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.” Based on a review of a sample of 789 Medicare beneficiaries discharged from acute care hospitals during October 2008, the OIG found that 13.5% of hospitalized Medicare beneficiaries experienced harm as a result of an adverse event during hospital stays. Such events included National Quality Forum Serious Reportable Events; Medicare hospital-acquired conditions; and events resulting in prolonged hospital stays, permanent harm, life-sustaining intervention, or death. The incidence rate projects to about 134,000 Medicare beneficiaries experiencing at least one adverse event in hospitals during a single month, with events contributing to the deaths of about 15,000 beneficiaries. According to the OIG, physician reviewers determined that 44% of these events were preventable, most commonly because of medical errors, substandard care, and inadequate patient monitoring. The OIG estimates the Medicare costs associated with the additional hospital care necessitated by these events to total about $4.4 billion annually. The OIG called for additional efforts to reduce the incidence of adverse events, with the Agency for Healthcare Research and Quality (AHRQ) and CMS leading these efforts. The OIG also recommended, among other things, that CMS provide further incentives for hospitals to reduce adverse events through its payment and oversight functions, including strengthening the Medicare hospital-acquired conditions policy and holding hospitals accountable for adopting evidence-based practices.