14% Reporting of Patient Harm Events

Those of us on the Community Ethics Committee are currently spending our days and nights struggling with the whole issue of Physician-Assisted Suicide (aka Death with Dignity or Aid in Dying). Perhaps that is why I was struck today by a news "blurb" about the reporting of patient harm stating "only an estimated 14% of patient harm events experienced by Medicare beneficiaries" were reported (from the OIG report summary). That means 86% of patient harm events were NOT reported!! Really!?!

"Hospitals investigated those reported events that they considered most likely to lead to quality and safety improvements and made few policy or practice changes as a result of reported events. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent)."

http://oig.hhs.gov/oei/reports/oei-06-09-00091.asp

Two thoughts - "Medicare beneficiaries" are more often than not those who are elderly or disabled and arguably less likely to advocate strongly for themselves; and, no matter how you define your terms and how generously you perceive this reporting "glitch", the fact that, of the total incidents of patient harm, only 14% were reported is extremely troubling.

Given the understandable rationale that aiding someone who wants to end their suffering is an act of supreme compassion, I can't help but wonder how many incidents of "oops! we didn't perceive harm" might occur in the area of Physician-Assisted Suicide. I know heaps and gobs of regulatory protective criteria are proposed, but . . . Protective criteria are already in place within our long-established Medicare system and even so, 86% of incidents of patient harm didn't see the light of day. Makes me a little bit afraid of the dark . . .