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Saturday, January 7, 2012

Harmful Hospital Errors are Vastly Underreported

In an article by the always informative Robert Pear in yesterday's New York Times we learn that a just-released study from the Inspector General of the Department of Health and Human Services reports that only one in seven errors, accidents, or other events that harm hospitalized Medicare beneficiaries gets recognized and reported. (As of today, the report itself isn't available on line.)

Quality improvement gurus teach that "every defect is a treasure." Sometimes recognizing that avoidable harm has occurred lets us help the involved patient, but there are always important lessons that can prevent repetition and help other patients in the future.

The unreported events were identified from detailed study of hospital records. They included
medication errors, severe bedsores, hospital-acquired infections, delerium from overmedication, and excessive bleeding linked to improper use anticoagulants. The Inspector General calculated that more than 130,000 Medicare beneficiaries experience this kind of injury each month!
What I found most disturbing is the Inspector General's surmise that the primary reasons for the underreporting were (a) not recognizing that avoidable harm had occurred or (b) seeing the incident as so common that it didn't need to be reported.
"Developing a culture of safety" is a common mantra, but we clearly have a long way to go to make it more than an empty cliche.

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