A quarter of hospitalized Medicare patients experience preventable harm, report finds

To reduce incidents, hospitals seek to identify and capture harm events within their incident reporting and other surveillance systems. They use this information to understand the harm that occurs in their facilities and guide their patient safety improvement activities. However, the report found that hospitals did not capture half of patient harm events that occurred among hospitalized Medicare patients.

In many cases, staff did not consider these events to be harm or explained that it was not standard practice to capture them. This often was because hospitals applied narrow definitions of harm. Of the patient harm events that hospitals captured, few were investigated, and even fewer led to hospitals making improvements for patient safety.

“Hospitals miss opportunities to learn from and reduce harm when their incident reporting or other systems fail to capture harm events,” the report said. “Our review found that these systems did not capture 49% of harm events that occurred among hospitalized Medicare patients in October 2018. Hospitals did not capture many of the harm events in their incident or other reporting systems, largely because they used narrow definitions of patient harm.”

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Researchers identified three common ways to capture harm events:

• Medical record review is a manual examination of a patient’s medical records to evaluate the care provided, including identifying errors and substandard care.
• Real-time patient monitoring systems include automated alerts and tools, using electronic health information at the bedside or recorded in medical records to identify patients who experienced harm events in real time.
• Hospital incident reporting systems gather and store information on patient safety incidents and other concerns, which can be used to monitor trends and trigger an investigation or other follow-up activities.

Over the last decade, investments in patient safety by HHS, health care providers and other groups likely have contributed to progress in hospitals capturing patient harm events within their incident reporting and other surveillance systems. Nevertheless, the study shows that hospitals miss many harm events, which calls for further action to improve hospital identification and investigation of patient harm.

“Although we cannot expect hospitals to capture every harm event that occurs, narrow definitions of harm or decisions about what should be captured limit hospitals’ ability to comprehensively identify harm,” the report said. “In addition, our findings show that many harm events that are known to hospitals may not be investigated, creating a knowledge gap that may contribute to the persistence of patient harm in hospitals. As a result, many hospitals are navigating a landscape of uncertainty about the harm that is occurring within their facilities and how to effectively respond to such events.”

The report recommends that the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services lead a national effort to align definitions across the health care industry and create a classification of patient harm in partnership with relevant federal partners and other stakeholders.

“In addition to serious events already tracked by existing programs, this new taxonomy could include the most common types of patient harm events classified by prevalence, clinical category, preventability, severity and other characteristics,” the report concluded. “By aligning these definitions, AHRQ and CMS would be supporting hospitals’ efforts to capture harm and would facilitate greater communication about the incidence of harm and safety practices within facilities and across the medical community.”