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Report says a quarter of hospitalized Medicare patients got improper treatment

Responding to such 'adverse' events hampered by confusing bureaucracy

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John Bazemore/AP

Surgeries performed on the wrong body part, instances of sexual assault and incorrect blood transfusions—these are just a sampling of the adverse events that more than a quarter of Medicare beneficiaries experienced while they were in treatment at hospitals, according to a month-long survey conducted as part of a recent Department of Health and Human Services inspector general’s report.

The Oct. 2008 survey of 81 hospitals found that 27 percent of Medicare beneficiaries experienced adverse events — medical errors or other improper treatment that result in patient harm — while in hospitals. But reduction of such adverse events has been hampered, the report says, by a complex and confused hospital oversight structure. The report, Adverse Events in Hospitals: National Incidence Among Medicare Recipients, was released last week.

Hospitals bear the primary responsibility for investigating adverse events, but who dictates how outside investigations should proceed is less clear. Hospitals that participate in the Medicare program must either be accredited by the independent, nationally recognized Joint Commission or demonstrate to the Centers for Medicare & Medicaid Services (CMS) that they are in compliance with a list of 23 Medicare conditions of participation, called CoPs.

Outside the scope of a hospital’s governing body, state agencies are responsible for investigating adverse events at hospitals. However, if the hospital is accredited by the Joint Commission, that state agency must report adverse events to CMS’s regional office and receive feedback from that office before beginning an investigation or making any recommendations. Even though 90 percent of hospitals elect to be accredited through the Joint Commission, CMS regional offices often failed to notify the commission of complaints, impeding the Commission’s oversight of its hospitals.

Increasing patient safety — that is, reducing the incidence of adverse events — has become a key priority for the health care community in recent years, but the complexity of the adverse events response process has made that goal difficult to achieve.

“Complaint investigations are inherently disruptive for hospitals,” the report said. “When complaints resulted in multiple responders, the disruption was magnified… In some cases, the hospitals observed that the magnitude of the responses appeared to be out of proportion to the likelihood of the alleged events’ recurring.”

Hospitals and state health agencies typically employ a patchwork of corrective actions to respond to adverse events. In 91 percent of the complaints included in the inspector general’s survey, hospitals provided staff with additional training. Policy changes and process changes were each included in hospitals’ responses 48 percent of the time.

But according to the report, state agencies need to improve communication with hospitals and accreditors. State agencies did not always explain to hospitals the nature of the complaints they received and “performed little monitoring to verify that hospitals’ corrective actions resulted in sustained improvements.”

CMS officials say they recognize the importance of doing all it can to increase patient safety.

“There is no greater opportunity for far reaching improvement in the experience of individuals and families in the United States health care system than in the arena of patient safety,” CMS Administrator Donald Berwick wrote in response to the inspector general’s report.

In response to multiple inspector general’s reports on adverse events, the Department of Health and Human Services instituted its Partnership for Patients  in April 2011. The $1 billion program will help hospitals implement strategies to reduce patient harm. HHS projects the partnership will save more than 60,000 lives over the next three years.

“We will provide hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals and hospitals to support their efforts to reduce harm,” Berwick said in a statement at the time the program was announced.

CMS’s response to the report was generally positive, and Berwick noted that CMS would incorporate the inspector general’s recommendations into its new program.

“We particularly appreciate this review of how we can use our authorities more effectively to reduce adverse events in hospitals,” Berwick said. “The recommendations of this report will help us strengthen the Partnership for Patients as we work together with hospitals and other health care providers to improve patient safety.”