Three of the systems reviewed had less-extensive disclosure of information about causes or prevention strategies. The disclosure concerned information about individual events or consisted of lists of events from submitted hospital reports. There was no root-cause analysis or indication of what events led to planned corrective actions.

The entities did all protect patient privacy concerns through policies, practices and legal provisions. The entities either did not collect or disclose patient identifiers, and most prohibited the compelled release of patient identifiers.


Five of the state systems reviewed did not collect any patient identifiers, including the patient's name or address. The remaining systems did not disclose patient identifiers publicly, but referenced patients in a manner to prevent identification, such as just by race, gender, age range and length of hospital stay. However, the OIG notes that some publications did have detail that could identify a patient under some circumstances, such as a patient in a smaller community or if media reports have other information that can be connected to disclosed information.

The report also states that the Centers for Medicare and Medicaid Services (CMS) is considering public disclosure of information concerning Medicare hospital-acquired conditions, which is a subset of adverse events. The disclosure may be posted on the CMS Compare web site, which contains quality measures about hospitals.

The OIG report did not have recommendations, but did note that the disclosure practices of the seven state systems with more extensive disclosure "can serve as models for other entities. These systems disclose analysis of the causes of events, evidence-based guidelines for reducing occurrences, and information about demonstrated improvements by hospitals. This type of information, if disseminated by other State systems and entities that receive adverse event information could help to improve patient safety."

Read more details:
The OIG report, with information on the state systems:
http://www.oig.hhs.gov/oei/reports/oei-06-09-00360.pdf

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