When we think of hospital stays, we think of terms like treatment, healing and safety. What we certainly don’t think of are terms such as adverse event or temporary harm event. However, a recent study performed by Department of Health and Human Services inspectors shows that these terms are a reality for over 25 percent of Medicare beneficiaries.

The study, prompted as part of the Tax Relief and Health Care Act of 2006, sought to definitively determine the incidence rates of both adverse events and temporary harm events among Medicare beneficiaries. In order to accomplish this, the inspectors randomly selected 780 Medicare beneficiaries discharged from hospitals across the country during a one-month period (October 2008) and determined how many suffered some degree of harm while hospitalized.

For those unfamiliar with the terms “adverse events” and “temporary harm event,” the DHHS provides the following definitions:

• 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.”
• Temporary harm event: “An event that requires intervention but does not cause lasting harm, such as an allergic reaction or hypoglycemia.”

What did the inspectors discover?

Shockingly, they made the following findings concerning the 780 Medicare beneficiaries discharged during October 2008:

• 13.5 percent experienced an adverse event and these adverse events proved deadly for 1.5 percent of beneficiaries
• 13.5 percent experienced a temporary harm event
• 44 percent of these adverse events and temporary harm events were otherwise preventable
• The total cost associated with these adverse and temporary harm events was $324 million

Perhaps even more shocking, the inspectors also examined the frequency with which hospital staff were reporting, tracking and analyzing adverse events, a requirement for participating in Medicare.

Here, inspectors found that while all hospitals had the reporting systems in place, staff failed to report 86 percent of adverse events. The reason? Inspectors cited inadequate time, fear of punitive action, a belief that reporting was fruitless, and a general lack of understanding as to what constitutes harm as the reasons behind the low figures.

In light of the above revelations, inspectors recommended that both the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services greatly expand their safety and education efforts, and provide incentives for compliance.

This study just goes to show that you can never take your safety for granted in a hospital setting, and that you should always take the necessary steps to make sure medical professionals are providing you or your loved one with the proper care.

Source: OIG HHS, “Spotlight on … Adverse Events,” July 20, 2012