Medicare Report Recommends Improving Records of Hospital Errors

Nov. 6, 2011 -- Medicare inspectors must do a better job of tracking reports of serious mistakes in care at the nation's hospitals, as well as of informing rating agencies of the errors, according to a report released Tuesday by the agency's inspector general.

Hundreds of serious errors go unrecorded, the report found, because the inspectors who find problems at hospitals don't tell the national agencies that accredit hospitals. That means that those hospitals continue to participate in Medicare and that they don't learn from their mistakes, Inspector General Daniel Levinson writes.

Also, Levinson writes, no one tracks the effectiveness of policy changes or how the hospitals actually correct mistakes.

Last year, the inspector general found that 15,000 Medicare patients die each month in part because of the treatment they receive in a hospital. Tuesday's report focuses on the worst errors — or "immediate jeopardy complaints." They include surgical fires, patient suicides, sexual assault, surgeries performed on the wrong patients and medical instruments left inside a patient after a surgery.

State survey and certification agencies check complaints and are supposed to report them to the Centers for Medicare and Medicaid Services (CMS). That should lead to a review to determine whether the hospital has fixed the problem and will still be allowed to work with Medicare.

However, the report shows, CMS regional offices notified hospital accreditors of only 28 of the 88 sampled immediate jeopardy complaints.

State agencies also only required the hospitals to provide performance data for one of the 19 cases that required corrective plans.

In some cases, state agencies did not inform the hospitals of the nature of the mistake, because they wanted to protect the complainant's identity. That meant the hospitals did not know what they needed to fix.

Researchers did not look at why the problems were occurring, according to IG officials, which raised the possibility that it could have been an oversight or the result of unclear instructions from CMS.

Levinson recommends the following steps:

•CMS should evaluate compliance with quality-assurance measurements.

•State agencies should monitor hospitals' improvements.

•CMS should make it clear that state agencies tell hospitals what mistakes they've made.

•CMS should notify accreditors when hospitals make mistakes.

In a response to Levinson, Medicare Administrator Don Berwick said that he agrees with the recommendations and that several improvement have already been made.

Both Levinson and Berwick said a new program, the Partnership for Patients, focuses on patient safety and should help with the reporting issues.