oig report patient harm

HHS OIG Finds Patient Harm in 25% Of Medicare Patients The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) just released a landmark study reporting that 25% of Medicare patients suffer patient harm and that 43% of those, or about 12% of the total, are preventable.

Full Answer

What's new with OIG's Medicare data?

OIG conducted a new study to update the national incidence rate of patient harm events among hospitalized Medicare patients in October 2018. This work included calculating a new rate of preventable events and updating the cost of patient harm to the Medicare program.

What is the incidence of patient harm events in hospitals?

In 2010, OIG reported the first national incidence rate of patient harm events in hospitals—27 percent of hospitalized Medicare patients experienced harm in October 2008. During that month, hospital care associated with these events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments.

How many Medicare patients experience patient harm during hospital stays?

Finally, we compared the results of this report to our 2010 report and explained the limitations of this comparison. Twenty-five percent of Medicare patients experienced patient harm during their hospital stays in October 2018. Patient harm includes adverse events and temporary harm events.

What is considered patient harm?

Forty three studies (60%) reported proportions of at least two of the following six types of preventable patient harm: drug management, non-drug therapeutic management, diagnosis, invasive medical procedures, surgical procedures, and infections acquired during healthcare.

What is a patient safety report?

The Patient Safety Reporting System (PSRS) is a non-punitive, confidential, and voluntary program which collects and analyzes safety reports submitted by healthcare personnel. Staff can report close calls, suggestions, and incident / event related information and data to improve patient safety.

What are formal reporting methods in health care?

The formal methods for reporting adverse events are incident reports, occurrence reporting, occurrence screening, and FMEA are methods that follow policies and procedures.

What is the difference between a sentinel event and an adverse event?

An Adverse Event is a serious, undesirable and usually unanticipated patient safety event that resulted in harm to the patient but does not rise to the level of being a Sentinel Event.

Why must a SI report be?

It is important that any incident suspected as a SI is notified to the Patient Safety Team as soon as possible. The notification ensures communication of incidents and the mobilisation of help and support. Even when it is decided an incident is not a SI the notification can be very valuable.

What is the process of reporting an incident?

Incident Report Sample Walkthrough: A Step-by-Step GuideStep 1: Provide Fundamental Information. ... Step 2: Take Note of Any Damages and Injuries. ... Step 3: Identify Affected Individual(s) ... Step 4: Identify Witnesses and Take Their Statements. ... Step 5: Take Action. ... Step 6: Close Your Report.

What are the 4 elements you should try to get when reporting an adverse event to patient safety?

The minimum dataset required to consider information as a reportable AE is indeed minimal, namely (1) an identifiable patient, (2) an identifiable reporter, (3) product exposure, and (4) an event.

What is the most common type of incident reporting event?

medication incidentsThe most common types were medication incidents (29%), falls (14%), operative incidents (15%) and miscellaneous incidents (16%); 59% seemed preventable and preventability was not clear for 32%. Among the potentially preventable incidents, 43% involved nurses, 16% physicians and 19% other types of providers.

Which types of events should be reported in a safety report?

All team members are required to participate in the detection and reporting of any error, medication error, near miss, hazardous/unsafe condition, process failure, injuries involving patients, visitors and staff or a sentinel event.

What are the 3 common factors of an adverse event?

The most common contributing factors were (i) lack of competence, (ii) incomplete or lack of documentation, (iii) teamwork failure and (iv) inadequate communication. Conclusions: The contributing factors frequently interacted yet they varied between different groups of serious adverse events.

What are the top 5 sentinel events?

The most common sentinel events are wrong-site surgery, foreign body retention, and falls. [3] They are followed by suicide, delay in treatment, and medication errors. The risk of suicide is the highest immediately following hospitalization, during the inpatient stay, or immediately post-discharge.

What qualifies as a sentinel event?

A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event.

More Than One in Four Medicare Beneficiaries Experience Some Degree of Harm While Hospitalized

Prompted by the Tax Relief and Health Care Act of 2006, OIG conducted a thorough examination of the issue of adverse events. Perhaps the most noteworthy outcome is a report describing the incidence rate of these events. Though others have attempted this challenging task previously, estimates of this rate varied widely.

Reporting Systems To Track Adverse Events Exist but Often Miss Events and Opportunities for Improvement

In addition to studying the frequency of adverse events, OIG examined adverse event reporting systems. Hospitals are required to track and analyze patient harm as a requirement of participating in Medicare, and in fact, all the hospitals in OIG's sample had such a system in place.

OIG Will Continue To Examine Adverse Events

OIG plans to continue exploring the complex yet vitally important issue of adverse events, looking beyond hospitals to other medical settings. One study underway is examining the frequency of adverse events in nursing homes, the factors that contributed to those events, and their costs to Medicare.

Additional Information

Adverse Event - An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care. This includes never events; hospital-acquired conditions; events that required life-sustaining intervention; and events that caused prolonged hospital stays, permanent harm, or death.