OIG: Disclosure of Adverse Events Limited

The Office of Inspector General (OIG) found that public disclosure of information about adverse events was limited, according to its review of 17 state adverse event report systems, eight Patient Safety Organizations overseen by the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare and Medicaid Services (CMS).

Varying extent of disclosure among state systems.  Among the entities reviewed, seven state systems disclosed more extensive information about the causes of adverse events and prevention strategies than the other state systems. Three other state systems disclosed less extensive information about the causes of the adverse events and prevention strategies.

AHRQ.  AHRQ anticipates creating the Network of Patient Safety Databases (NPSD) to provide an evidence-based management resource for providers, patient safety organizations, and other entities. Patient Safety Organizations (PSOs) will submit adverse event information received from hospitals to the NPSD, which will allow AHRQ to receive and publicly disclose non-identifiable adverse event information.

Once the NPSD is operational, the Patient Safety Act requires that the data be used to analyze national and regional statistics, including trends and patterns of reported adverse events, and to generate two public reports on: (1) effective strategies for reducing medical errors and increasing patient safety, and (2) trend analysis results. The initial NPSD data is estimated to be available for analysis and disclosure in early 2011.

CMS.  CMS has selected ten categories of conditions for the Medicare hospital-acquired condition policy, and presently denies hospitals higher payment for Medicare admissions complicated by the ten conditions. CMS is considering posting the incidence of hospital-acquired conditions on its Hospital Compare Website, which presently includes other quality measures about hospitals. Medicare claims data, however, lack information about the causes of hospital-acquired conditions or prevention strategies.

Patient privacy.  Every entity reviewed by the OIG had patient privacy protections in place that varied in scope.

OIG Report, No. OEI-06-09-00360, Jan. 5, 2010