Adverse events that harm patients are publicly reported unevenly, according to a report from the inspector general for the Department of Health and Human Services.
The report reviewed the public disclosure of the information by state adverse reporting systems, patient safety organizations and the Centers for Medicare & Medicaid Services. As the report points out, reporting such events can help educate health care providers about why such events happen and how to prevent them.
The report (Adverse Events in Hospitals: Public Disclosure of Information about Events OEI-06-09-00360) does highlight seven state systems that are disclosing more information than others: Maryland, Massachusetts (both the Board of Registration in Medicine and the Department of Public Health), Minnesota, New Jersey, Oregon and Pennsylvania.
The inspector general points to those systems as models:
The disclosure practices of the seven State systems with more extensive disclosure can serve as models for other entities. These systems disclose analysis of the causes of events, evidence-based guidance for reducing occurrences, and information about demonstrated improvements by hospitals. This type of information, if disseminated by other State systems and entities that receive adverse event information, could help to improve patient safety.
The report provides some useful information for journalists about what information is publicly reported and AHCJ is, of course, gratified to see a government report that advocates public disclosure of patient safety information.
Cheryl Clark of HealthLeaders Media wrote about the report.