One in Four Hospitalized Medicare Patients 'Harmed' in Hospital

But hospitals do a poor job of recognizing, tracking, and fixing problems.

• 25% of hospitalized Medicare patients suffered harm in hospital

• 43% of those cases were preventable

Teaching hospitals “missed” cases of harm at a far greater rate than other hospitals

In a telling revelation about the state of patient safety in U.S. hospitals, a new report from the Health and Human Services' Office of Inspector General (OIG) has uncovered startling proof that hospitals failed to document nearly half of all “patient harm events” suffered by Medicare patients.

The report highlights how this oversight stems from inconsistent interpretations as to what constitutes "harm," and leaves hospitals without crucial dat to prevent future incidents. It also arguably gives them plausible deniability when they don’t fix their issues.

Read on for details.

OIG defined patient harm as any undesirable clinical outcome—not caused by

underlying disease—that was the result of medical care or that occurred in a health

care setting, including the failure to provide needed care.

This could include cases of botched surgery, adverse events from medicine, patient given the wrong information or dose, misdiagnoses, hospital-acquired infections, and more.

The new analysis draws from a sample of 299 “harm events” documented in an earlier OIG study. That study, published in October of 2018, found that one in four hospitalized Medicare patients suffered harm, with 43% of those cases preventable.

The new OIG report says there’s been progress but persistent gaps remain.

The OIG's investigation involved surveying 154 hospitals about 266 of the events referred to in 2019. It revealed that hospital staff often overlooked harms because they viewed them as routine complications or side effects of treatment (46% of missed cases), or because hospital policies didn't require reporting unless the outcome was severe, like serious injury or death (16%).

Other reasons why harm went unaddressed included difficulty distinguishing harm from a patient's underlying condition (20%) or events occurring after the patient was discharged from the hospital and there wasn’t appropriate follow-up (4%).

Notably, surgery- and procedure-related harms were missed at a higher rate (73%) than other categories like medication errors or infections (54%), potentially because these are seen as inherent risks.

Teaching hospitals, which handle more complex cases, fared worse than other hospitals, missing a startling 62% of harm events compared to 46% in non-teaching facilities.

Another shortfall was revealed in processes even when harms were captured. Only a fraction (about 35%) were actually investigated. This low follow-through, the report argues, creates a "knowledge gap" that perpetuates harm, with some serious cases involving permanent injury or death going unaddressed.

Looking ahead, the OIG is calling for stronger federal leadership to standardize harm definitions and create a comprehensive "taxonomy" of patient harm events, involving agencies like the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS) alongside “industry partners.”

The OIG says this would help hospitals capture a broader range of incidents, from common preventable errors to rare severe ones. Meantime, without better tracking and accountability, the cycle of avoidable harm in America's hospitals could continue, affecting vulnerable Medicare beneficiaries and beyond.

Read the report for yourself here: https://oig.hhs.gov/documents/evaluation/10840/OEI-06-18-00401.pdf

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