Report: Hospitals Did Not Capture Half of Patient Harm Events, Limiting Information Needed to Make Care Safer

The U.S. Department of Health and Human Services Office of Inspector General (OIG) report on patient harm events in hospitals reports that hospitals did not capture half of the OIG-identified patient harm events that occurred among hospitalized Medicare patients, nor investigate all harm events they did capture, limiting hospitals’ ability to make improvements for patient safety. For this report, HHS-OIG traced harm events identified in a 2022 report on the incidence of harm in hospitals to examine whether hospitals captured those events in their incident reporting or other surveillance systems and to understand what actions they took in response.

The OIG issued three recommendations: the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) work with Federal partners and other organizations to align harm event definitions and create a taxonomy of patient harm to drive a more comprehensive capture rate of harm events; CMS ensure that surveyors prioritize the Medicare Quality Assurance and Performance Improvement (QAPI) requirement to hold hospitals accountable for patient harm; and, CMS instruct Quality Improvement Organizations to use information about harm events to assist hospitals in identifying weaknesses in their incident reporting or other surveillance systems.