Where To Report Waste

Fraud, Abuse, Or Retaliation

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018

Submitting OIG:

Department of Health & Human Services OIG

Date Issued:

Thursday, May 5, 2022

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

OEI-06-18-00400

Component, if applicable:

Centers for Medicare & Medicaid Services

Centers for Medicare and Medicaid Services

Location(s):

United States

Type of Report:

Inspection / Evaluation

Questioned Costs:

$0

Funds for Better Use:

$0

Number of Recommendations:

7

View Document:

Attachment	Size
OEI-06-18-00400.pdf	1.29 MB

Related Open Recommendations

Recommendation Number	Recommendation Status	Significant Recommendation	Additional Details
22-E-06-017.01	Open	No
CMS should update and broaden its lists of hospital-acquired conditions to capture common, preventable, and high-cost harm events.
22-E-06-017.02	Open	No
CMS should explore expanding the use of patient safety metrics in pilots and demonstrations for health care payment and service delivery, as appropriate.
22-E-06-017.03	Open	No
CMS should develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm events.
22-E-06-017.04	Open	No
AHRQ should, with support from HHS leadership, coordinate agency efforts to update agency-specific Quality Strategic Plans.
22-E-06-017.05	Open	No
AHRQ should optimize use of the Quality and Safety Review System (QSRS), including assessing the feasibility of automating data capture for national measurement and to facilitate local use.
22-E-06-017.06	Open	No
AHRQ should develop an effective model to disseminate information on national clinical practice guidelines or best practices to improve patient safety.
22-E-06-017.07	Open	No
AHRQ should continue efforts to identify and develop new strategies to prevent common patient harm events in hospitals.