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Hospital Staff Often Fails to Report Mistakes: Part 1

Children call them boo-boos, uh-ohs or oopsies. Many people simply know them as mistakes. Hospitals, whether they are in Ohio or in any other state, refer to them as adverse events.

These "adverse events" can be serious as they include getting the wrong medications, developing bedsores, and acquiring preventable or hospital-based infections. According to The New York Times, the inspector general recently estimated that among Medicare patients alone, more than 130,000 experienced at least one adverse event in the course of one month in hospitals around the country.

Yet, a recently released report by federal investigators shows that hospital workers overwhelmingly do not report adverse events affected Medicare patients when they happen. The report says that only one in seven errors and accidents affecting Medicare patients are reported, even when these errors result in a patient's death.

Why not? The federal government investigation pointed to a number of possible reasons, but the report listed as the most prevalent reason that hospital personnel were not knowledgeable enough to recognize just what is an adverse event or that it should be reported.

In some cases, hospital staff just assumed someone else would do it. Other times, hospital staff did not want to admit their own mistakes. Whatever the case, the lack of reporting raises serious concerns to government regulators because it is a condition of receiving Medicare funds that hospitals report adverse events affecting Medicare patients and take steps to improve patient care.

The next blog post will continue to discuss this issue.

Source: The New York Times, "Report Finds Most Errors at Hospitals Go Unreported," Robert Pear, Jan. 6, 2012

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