According to a recent report issued by Medicare, hundreds of serious hospital errors go unreported and unrecorded because inspectors are not informing the national agencies responsible for accrediting hospitals or the federal agencies responsible for oversight. According to Medicare Inspector General Daniel Levinson, failing to report these errors allows hospitals to continue to operate in the Medicare program without correcting mistakes and can seriously impact patient health and safety.
According to USA Today, (an astonishing) approximately 15,000 Medicare patients die each month because of the treatment they receive in a hospital or medical facility. However, the Inspector General’s current report focuses only on the serious errors or “immediate jeopardy complaints,” which include such actions as surgical fires, sexual assaults against patients, patient suicides, instruments mistakenly left in patients and operations on the wrong body parts or the wrong patient. The failure of reporting these errors can be potentially fatal to the patient, are costly the Medicare system and expose physicians to medical malpractice.
In theory, Medicare inspectors from state certification agencies are supposed to check complaints and report them to the Centers for Medicare and Medicaid Services, and then these reports should lead to a review of the hospital and its corrective procedures. Yet the state agencies and its inspectors are not reporting this information to CMS. The report found that the CMS regional offices notified hospital accreditors of only 28 of the 88 serious complaints surveyed. In addition, the state agencies are not requiring the hospitals to provide data on whether their corrective plans are working. The report also argues that the state inspectors may not be reporting the mistakes because they want to protect the complainant’s identity.
Inspector General Levinson made several recommendations to improve the reporting of serious hospital errors. Specifically, he recommended:
- State agencies should better monitor hospital improvements
- CMS should assess compliance with quality assurance measurements
- CMS needs to clarify reporting requirements to ensure state agencies tell hospitals what mistakes have been made
- CMS must improve communication and notify national accreditation agencies when hospitals make mistakes
The report concludes that Medicare’s system of hospital oversight has missed opportunities to address patient safety and these reforms, if enacted, will improve the system.
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