OBJECTIVE
To evaluate the usefulness of selected methods for identifying events that harm hospitalized Medicare beneficiaries.
BACKGROUND
The term “adverse event” describes harm to a patient as a result of medical care or harm that occurs in a health care setting. The term “never events” refers to a specific list of serious events, such as surgery on the wrong patient, that the National Quality Forum deemed “should never occur in a healthcare setting.” The Tax Relief and Health Care Act of 2006 (the Act) mandated that the Office of Inspector General (OIG) report to Congress about such events, including making recommendations about processes for identifying events. To meet the requirements of the Act, OIG published a series of reports in 2008 and will publish additional reports based on ongoing work.
In 2008, OIG conducted a case study to determine the incidence of adverse events (hereinafter referred to as events) by reviewing a random sample of 278 Medicare beneficiary hospitalizations selected from all Medicare discharges from acute care hospitals in two selected counties during a 1-week period in August 2008. Using a two-stage review process, the case study identified 120 events. The first stage consisted of using five selected methods to screen for events, including nurse reviews of medical records, interviews of Medicare beneficiaries, two types of billing data analysis, and reviews of internal hospital incident reports. Each time a screening method indicated the possibility that an event occurred during the hospitalization, researchers designated the possible event as a “flag.” The second stage consisted of physician reviews of medical records for 183 of the 278 beneficiary hospitalizations—those with at least 1 flag. This report provides an indepth examination of the usefulness of the five screening methods used for identifying events. OIG considered the most useful methods to be those that identified the greatest number of events.
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