Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized, federal investigators say in a new report.
Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the "adverse events," according to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services.
In the report, being issued on Friday, Mr. Levinson notes that as a condition of being paid under Medicare, hospitals are to "track medical errors and adverse patient events, analyze their causes" and improve care.
Nearly all hospitals have some type of system for employees to inform hospital managers of adverse events, defined as significant harm experienced by patients as a result of medical care.
"Despite the existence of incident reporting systems," Mr. Levinson said, "hospital staff did not report most events that harmed Medicare beneficiaries." Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.
Adverse events include medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.
Federal investigators identified many unreported events by having independent doctors review patients' records.
The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.
Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said.
When the National Academy of Sciences issued a landmark report on patient safety in 1999, many experts said that hospital employees were often afraid to admit mistakes. But that no longer appears to be the main obstacle to reporting, federal investigators said.
More often, Mr. Levinson said, the problem is that hospital employees do not recognize "what constitutes patient harm" or do not realize that particular events harmed patients and should be reported.
In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or "suspected that the events were isolated incidents unlikely to recur."
To clear up confusion, Medicare officials said they would develop a list of "reportable events" that hospitals and their employees could use. In addition, the Medicare agency said, hospitals should give employees "detailed, unambiguous instructions on the types of events that should be reported."
The Obama administration and hospital industry leaders have placed a high priority on reducing medical errors. But, the report said, at many hospitals, this high-level commitment has not been translated into practice.
The inspector general found that "hospitals made few changes to policies or practices" after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any "systemic quality problems."
Organizations that inspect and accredit hospitals generally "do not scrutinize" how hospitals keep track of medical errors and other adverse events, the study said.
The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said.
More than 2,900 hospitals have joined the administration in a "partnership for patients" intended to reduce errors and save 60,000 lives in three years.
At least 27 states have laws that require hospitals to report publicly on infections that patients develop in the hospital, according to the National Conference of State Legislatures, up from 6 at the end of 2005.
In view of the state laws, Obama administration officials said they were not proposing new federal requirements for the public reporting of adverse events.