A government report issued this past January paints a troubling portrait of hospital care in America. According to the study, thousands of patients experience hospital oversights including “adverse events” every month. The data also shows that hospitals have a poor record of reporting mistakes and implementing improved protocols to prevent medical mishaps from recurring in the future.
What is an Adverse Event?
Adverse events can encompass a wide range of shortcomings. Defined officially as “significant harm experienced by patients as a result of medical care,” some of the more common adverse events include:
- Medication errors
- Infections associated with use of a catheter
- Severe bedsores
- Overuse of painkillers resulting in delirium
- Excess bleeding resulting from the incorrect use of blood thinners
In the study, the Office of the Inspector General of the U.S. Department of Health and Human Services (HHS) reviewed patient records of 189 hospitals. The study revealed that a number of patient safety deficiencies were happening all across the American hospital industry.
Additionally, after investigators selected a nationally representative sample of Medicare beneficiaries, independent doctors reviewed data to determine whether adverse events occurred, and if so, whether they were properly reported or addressed through internal improvement mechanisms.
Unfortunately, many of the incident reporting systems currently in place proved woefully inefficient.
Researchers Find Deficiencies Go Unreported
By official estates, more than 130,000 Medicare beneficiaries experience at least one adverse event in any given month. Of these, the HHS study found 86 percent go unreported in official hospital incident reporting systems.
In many cases, inadequate reporting resulted from the failure of hospital staff to recognize adverse events as incidences that should be brought to the attention of hospital managers. Of the total adverse events, 61 percent were not reported because staff did not perceive them as reportable. The remaining 25 percent of unreported adverse events were events that staff members normally report, but for some reason did not report in these particular cases. Fear of retribution or the undesirability of “snitching” on their own colleagues are two reasons cited by HHS officials as to why some staff members failed to report adverse events.
Addressing the Underreporting Of Medical Errors
In order to receive Medicare payments, federal regulations require hospitals to “track medical errors and adverse patient events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the hospital.” Yet, even of the adverse events in the HHS study that were properly reported, 30 percent were not investigated further by the hospitals, and just 12.5 percent led to actual changes in policies or practices.
Medicare officials plan to reduce confusion about what issues should be reported by releasing a list of “reportable events” to hospitals. Hospitals would then be responsible for familiarizing employees with the list and providing detailed instructions regarding the types of events that need to be reported. However, the HHS study made it clear that there are significant challenges to improving medical mistake reporting, chief among them included the fact that organizations responsible for inspecting and accrediting hospitals generally do not scrutinize how hospitals keep track of adverse events.
All the hospitals reviewed in the HHS study had an incident reporting system in place; but, there is serious doubt as to whether these systems are doing enough to prevent harm to patients. While systematic or political fixes seem to be far on the horizon, families affected by adverse events can pursue individual solutions by filing medical malpractice claims against their doctor or hospital.
Malpractice claims can help parties injured through hospital negligence collect compensation for economic damages, like past and future medical expenses, wages lost due to incapacitation, and a depreciated future earning capacity. Noneconomic damages, such as compensation for pain and suffering or loss of companionship, are also recoverable. For especially egregious instances of wrongdoing, punitive damages may even be levied against offending hospitals.
In addition to helping the parties harmed by hospital mistakes collect compensation, medical malpractice suits provide a direct, meaningful incentive for hospitals to change behaviors that threaten patient safety. While federal regulations provide specific safety guidelines for hospitals, they frequently go unenforced or lack the teeth to cause real change. A patient lawsuit, on the other hand, is a highly visible, often financially significant episode for a hospital. Unlike federal regulations, medical malpractice lawsuits do not provide a theoretical safety framework that hospitals are encouraged to aspire to (albeit free of consequences) – they are a real world engine of change that directly links the cause and effort of medical errors in the mind’s eye of hospital administrators.