September 18, 2008 | Mark Paradies

Are Hospital Mistakes Under-Reported? What is the Root Cause?

Even where reporting of hospital mistakes (sentinel events) is required, some people point to actual mistakes that were NOT reported. This suggests that mistakes are under-reported.

The Philadelphia Inquirer wrote this article about the problem:

http://www.philly.com/inquirer/home_top_stories/20080912_Hospitals__mistakes_are_going_unreported.html

How bad is it? The Inquirer reports:

“In New Jersey, five of the state’s 80 hospitals failed to report a single preventable mistake last year, officials said. In Pennsylvania, some facilities didn’t report any serious events or even the near misses that might have harmed patients.”

And both Pennsylvania and New Jersey REQUIRE (by law) that many types of sentinel events be reported. Perhaps these hospitals are so good that they never make mistakes?

I believe that in addition to performing a root cause analysis on the causes of the sentinel events that they failed to report, the hospitals should also perform a root cause analysis on the reasons that the sentinel events were not reported in the first place. My guess is that the hospital administrators aren’t enforcing the SPAC (Standards, Policies, and Administrative Controls) for reporting sentinel events.

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