Hospitals rely on reporting systems
Report says there is little effect
Administrators from all hospitals with reported events indicated that they rely on incident reporting systems to capture a large portion of the information about events that they use to conduct patient safety improvement activities, but they are not capturing most errors, according to a new report by the Department of Health and Human Services (HHS).
The administrators acknowledged that incident reporting systems provide incomplete information about how often events occur, but they continue to rely on the systems primarily because they value staff accounts of events, the report says.
These are more findings from the report:
Nurses most often reported events, typically identified through the regular course of care.
Nurses most often identified events through patient observation and routine hospital safety assessments.
Twenty-eight of the 40 reported events led to investigations, and five led to policy changes.
Information regarding one-quarter of events was not accessible to the staff responsible for monitoring patient safety within the hospitals and for making policy changes.
Hospitals investigated the events they considered most likely to yield information that would inform quality and safety improvement efforts and made few changes to policy or practices as a result of reported events.
Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected. Accreditors view incident reports within the context of larger hospital quality and patient safety efforts.
Officials indicated that to assess hospitals, surveyors are most likely to review the results rather than review the methods used to track hospital adverse events. Surveyors would not specifically investigate these methods, such as incident reporting systems, unless evidence of a problem emerged through the survey process.