OIG Releases Reports on Hospital Adverse Events and State Reporting Systems

December 16, 2008
OIG Releases Reports on Hospital Adverse Events and State Reporting SystemsOn December 16, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) released a report entitled "Adverse Events in Hospitals: Overview of Key Issues."



The Tax Relief and Health Care Act of 2006 (Act) mandates that the OIG report to Congress regarding the incidence of "never events" among Medicare beneficiaries, payment by Medicare or beneficiaries for services furnished in connection with such events, and the process that the Centers for Medicare & Medicaid Services uses to identify events and deny payment. According to the OIG, this report is one in a series to fulfill the requirements of the Act.

In this report, the OIG identifies 7 issues critical to understanding adverse events in hospitals. In brief, the 7 issues can be described as follows:

Estimates of the incidence of adverse events in hospitals vary widely and measurement is difficult.
Nonpayment policies for adverse events are gaining in prominence and are viewed as a powerful incentive to reduce incidence but raise potential drawbacks.
Hospitals rely on staff and managers to report adverse events internally, but barriers can inhibit reporting.
Hospitals report adverse events to various oversight entities, although stakeholders suspect substantial underreporting.
Public disclosure of adverse events can benefit patients but also raises legal concerns for patients and providers.
Information to help prevent adverse events is widely available, but some hospitals and clinicians may be slow to adopt or routinely apply recommended practices.
Interviews and literature reveal strategies that may accelerate progress in reducing the incidence of adverse events in hospitals.
On December 16, 2008, the OIG has also released a related report entitled "Adverse Events in Hospitals: State Reporting Systems" in which the OIG identifies and describes state adverse event reporting systems and how states use the reported information. In brief, the OIG reports the following:

As of January 2008, 26 states had hospital adverse event reporting systems and another state had taken action to develop one.
Reporting systems varied in terms of what events were reported, criteria used for selection, and type of information reported.
Most states with systems reported having mechanisms to identify underreporting and strategies to improve reporting.
23 states reported using data to hold individual hospitals accountable and 18 states reported using data to promote learning and prevent adverse events.
In this report, the OIG concludes that state systems are disparate making state adverse event reporting systems data unsuitable for use in the aggregate to identify national incidence and trends. However, the OIG reports that most states use the reported data in similar ways. For instance, states use reports to assess individual hospitals' responses to adverse events, and to promote learning and prevent adverse events.

For purposes of the OIG reports, the OIG expanded beyond the term "never events" to address "adverse events," which describe patient harm resulting from medical ca
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