Underreported safety events a national concern

Editor's Note

A recent report on patient harm events by number and type from the Department of Health and Human Services (HHS) Office of Inspector General (OIG) was explored in a December 2 article in HealthAffairs.

The OIG reviewed medical records of 770 hospitalized Medicare patients who were discharged in October 2018 and identified nearly 300 incidents of patient harm. The most common type of harm identified  was medication-related errors at 43% such as incorrect dosing, adverse reactions with other medications taken, and allergic reactions, per the article.

In addition to the incidence of patient harm events being a concern, the article also discussed concern with underreporting safety events, as not all harms noted in the OIG review were investigated by the hospitals where the harm occurred. Fewer of the reported safety events resulted in meaningful safety improvements.

A closer look at factors contributing to underreporting, despite mechanisms like root-cause analyses, peer reviews, and morbidity and mortality conferences, was discussed in the article, including:

*A lack of standardized definitions of types of patient harm
*A lack of resources to address patient harm
*A lack of psychological safety to openly discuss it

A lack of resources such as time and staff was another recognized factor for underreported patient harm events discussed in the article. Rural hospitals, particularly in underserved areas, may have even less resources to investigate safety events.