Although half of States operated adverse event reporting systems in 2008, only 12 percent of events met State requirements for reporting, according to a report by the Office of the Inspector General.
For the report, the OIG reviewed state policies on which event types were required to be reported to the states. The OIG then examined medical records for 780 randomly selected Medicare patients.
Key findings include:
60 percent of adverse and temporary harm events nationally occurred at hospitals in States with reporting systems, yet only an estimated 12 percent of events nationally met State requirements for reporting.
Nearly all unreported events also went undetected by internal hospital incident reporting systems.
Of the events that States required to be reported, over half occurred in Pennsylvania, which required reporting of all events regardless of severity.
The OIG concludes that CMS, States, and other stakeholders should be aware of this low rate of reporting to State systems as they consider strategies to reduce adverse events in hospitals.