The Department of Health and Human Services Office of Inspector General has released a Memorandum Report, "Adverse Events in Hospitals: Public Disclosure of Information of Events." As the OIG describes, an adverse event is harm to a patient that results from medical care or happens in a health care setting. Adverse events can indicate medical errors, but do not always involve errors or negligence, nor are they always preventable.

The OIG says in the report that public disclosure of adverse event information has both benefits and unintended negative consequences. As example, the OIG points out, the disclosure serves to educate health care providers about the cause of such events. This can potentially lead to patient safety improvement. However, the reporting could also undermine patient privacy or, by naming the hospital, discourage event reporting.

For this report, the OIG focused on inpatient admissions to acute care hospitals. The OIG reviewed policies, practices, and plans for publicly disclosing information about adverse event causes and prevention strategies, while protecting patient privacy, from 17 selected State adverse event systems.

The OIG's results found that public disclosure of information concerning adverse events was disparate among the health care entities in the review. Seven state systems in the study publicly disclosed more extensive information and analysis about the causes of adverse events and about prevention strategies than the other state systems. The OIG says these seven systems provided information that could educate the medical community on the prevention or reduction of adverse events. The disclosures involved information the hospitals took to correct identified vulnerabilities, risk reduction strategies, and demonstrated improvements by the respective hospitals. The seven systems were in Minnesota, Maryland, New Jersey, Oregon, Pennsylvania, and two in Massachusetts.

As example in the report, one state system published an article concerning anticoagulant adverse events with information from hundreds of adverse event reports received by the system, as well as data from evidence-based research. The system summarized the details about the events: the level of patient harm, the identified causes. The article also recommended that hospitals establish anticoagulation management service programs to document the services, educate patients and families, and keep track of progress in improving performance. The system staff also followed up six months after distribution of the article and discovered that over half of hospitals in the state had reported changes initiated due to the article.

More Industry Headlines