Per the notice below, the Office of the Inspector General (OIG) of the United States Department of Health and Human Services (HHS) has issued three reports on hospitals and patient safety issues.
Hospitals Did Not Capture Half of Patient Harm Events, Limiting Information Needed to Make Care Safer (OEI-06-18-00401)
In 2022, OIG published a report determining that 25 percent of Medicare enrollees hospitalized in October 2018 experienced patient harm during their hospital stays. In this new report, OIG traced the harm events that we identified in 2022 to examine whether hospitals captured those events in their own incident reporting or other surveillance systems and to understand what actions they took in response. Hospitals did not capture half of patient harm events that occurred among hospitalized Medicare patients. Of the patient harm events that hospitals captured, few were investigated, and even fewer led to hospitals making improvements for patient safety.
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Hospitals Reported Few Captured Patient Harm Events to CMS and States (OEI-06-18-00402)
This is a companion report to Hospitals Did Not Capture Half of Patient Harm Events, Limiting Information to Make Care Safer. This memorandum report provided to the Centers for Medicare and Medicaid Services (CMS) raises concerns that hospitals are not consistently following reporting requirements intended to monitor patient safety. We determined that hospitals nationwide identified and captured in their incident reporting (or other surveillance systems) 94 harm events experienced by Medicare patients with stays ending in October 2018. Per CMS and State requirements, hospitals were obligated to report 15 (16 percent) of the harm events to external entities. Yet, in our sample, hospitals reported only five events.
Read the Full Memorandum Report
CMS Should Take Additional Actions To Help Hospitals Prepare for a Future Emerging Infectious Disease Outbreak (A-02-22-01019)
OIG released an audit building upon prior work to assess the operating effectiveness of CMS controls related to emerging infectious disease outbreaks. OIG identified gaps in CMS controls that could negatively affect hospital preparedness during a future event with a scope and duration similar to that of the COVID-19 pandemic. The audit found CMS’ oversight of hospital surveyors did not ensure that surveyors were trained to cover key planning areas for an emerging infectious disease outbreak.
Read the Full Report |
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