One of the most important ways to improve patient care in any hospital is for employees to report harmful mistakes that occur in treatment. Other businesses regularly use these techniques to improve efficiency and safety but it apparently is not happening with any frequency in hospitals. In a recent report involving Medicare patients issued by the Department of Health and Human Services, the inspector general noted that most adverse events in hospitals which affected Medicare patients were not being reported by employees. These events included medication errors, bedsores, excessive bleeding caused by overuse of blood thinners, infections, etc. Some of these events resulted in patient death. Medicare estimates that 130,000 Medicare patients suffered adverse events in hospitals in a single month last year.
As a result of this study, Medicare is developing a new list of reportable events which hospitals and their employees are required to report. The hope is that if employees are encouraged by hospitals to report these events, the hospitals can make necessary policy changes to make care safer for everyone. To date, few hospitals have instituted changes after adverse events are reported. For all of our safety, this has to change. A 1999 report from the Institute of Medicine estimated that 98,000 Americans die each year from hospital errors and more than a million are injured.