Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events

摘要

The Tax Relief and Health Care Act of 2006 requires that the Office of Inspector General (OIG) report to Congress regarding the incidence of never events among Medicare beneficiaries, among other topics.1 (For the relevant text of this Act, see Appendix A.) To meet the requirements of this Act, OIG released a series of reports beginning in 2008 and will publish additional reports based on ongoing work. (See Appendix B for a list of OIG reports in the series.) The published reports assessed State adverse event reporting systems, public disclosure of adverse events, and the national incidence of adverse events among the Medicare population. This report supplements that body of work by assessing the responses of State survey and certification agencies (State agencies) and CMS to complaints that allege serious adverse events. It also describes the hospitals responses, which helps in understanding the backdrop against which the former responds. These responses represent important patient safety opportunities, yet little attention has been paid to their role in improving patient safety. The objectives of this report were to (1) To assess the responses of State survey and certification agencies and the Centers for Medicare & Medicaid Services (CMS) to complaints that allege serious adverse events; and (2) To describe hospital responses to complaints that allege serious adverse events.