Editor’s Notebook

January / February 2012

Editor’s Notebook

Technology and Culture

Each year, the January/February issue of PSQH is distributed at the HIMSS conference and exhibition, the largest annual event focused on health information technology, which takes place this year Feb. 20 to 24 in Las Vegas. Accordingly, this issue  has a higher than average percentage of articles about technology and information systems, including electronic medical records, device integration, “big data,” business intelligence software, and adverse event reporting systems.

While this issue was in production, the Office of the Inspector General (OIG) issued a timely reminder that all efforts to improve the safety and quality of healthcare—including those that involve technology—depend primarily on culture for success.

In Hospital Incident Reporting Systems Do Not Capture Most Patient Harm, the OIG reports that only 14% of adverse events in hospitals are captured in incident reporting systems. Even more discouraging, administrators at all hospitals included in the study report that “they rely on incident reporting systems,” which we now know miss 86% of adverse events, “to capture much of the information used to conduct patient safety improvement activities.”

In the study, the OIG revisited 302 incidents of preventable harm it had identified in a report published in November 2010 that estimated the incidence of preventable harm to hospitalized Medicare patients. The data came from a survey of hospitals selected at random in October 2008. For the recent study on incident reporting systems, OIG staff members surveyed the 195 hospitals where the 302 incidents had occurred in order to determine how many of those events had been captured in the hospitals’ reporting systems. The OIG’s survey received a 97% response rate. In addition to the survey, staff from the OIG interviewed administrative staff at each of the 34 hospitals where incidents had been captured in reporting systems.

Why were so many events not reported? The OIG found that hospital staff members lacked a shared understanding of what constitutes patient harm. All hospitals in the study expected staff to report patient safety problems but none maintained a list of events that must be reported. Of the 253 events not reported, 62% were missed because staff members did not perceive the event as reportable or because it was not caused by perceptible error, was considered to be an expected outcome or side effect, the harm was slight or common, or because the harm became apparent after discharge. Twenty-five percent of events with harm were considered to be “commonly reported” but missed in these instances because clinicians were too busy, assumed someone else would report, or because they feared disciplinary action.

The OIG’s report is a reminder that technology is always a tool, not a solution. Technology allows organizations and individuals to practice medicine more safely and efficiently than is otherwise possible, but only when deployed in a system that provides the support, training, and culture necessary for safety and quality to flourish.

Levinson, D. R. (2012, January). Hospital incident reporting systems do not capture most patient harm. Office of the Inspector General, Dept. of Health and Human Services. http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf
Levinson, D. R. (2010, November). Adverse events in hospitals: National incidence among medicare beneficiaries. Office of the Inspector General, Dept. of Health and Human Services. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf