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

Date Issued

Thursday, May 5, 2022

Submitting OIG

Department of Health & Human Services OIG

Other Participating OIGs

Department of Health & Human Services OIG

Agencies Reviewed/Investigated

Department of Health & Human Services

Components

Centers for Medicare and Medicaid Services

Report Number

OEI-06-18-00400

Report Type

Inspection / Evaluation

Number of Recommendations

Questioned Costs

Funds for Better Use

Open Recommendations

This report has 7 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
22-E-06-017.01	No	$0	$0
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	No	$0	$0
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	No	$0	$0
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	No	$0	$0
AHRQ should, with support from HHS leadership, coordinate agency efforts to update agency-specific Quality Strategic Plans.
22-E-06-017.05	No	$0	$0
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	No	$0	$0
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	No	$0	$0
AHRQ should continue efforts to identify and develop new strategies to prevent common patient harm events in hospitals.