86% of Medical Error Goes Unreported

Hospital incident reporting systems were informed of only 14% of errors that harmed Medicare patients, according to this report on a recent survey undertaken by the Department of Health and Human Services Office of Inspector General. Hospital staff didn't perceive 61% of adverse events as reportable. Another 25% were classified as of a type commonly reported, but somehow not reported this time.

Remember what the Institute of Medicine told us, back in 1999, about how we ought to be dealing with medical errors? We're supposed to report them all, in a blame-free atmosphere, in order to gather information that will help us change the systems which give rise to them. The idea was that we'd make more progress by reporting error in this blame-neutral way than by either a) covering the error up or b) blaming error on particular human beings. The basic assumption was that most medical error resulted from flawed systems (training systems, oversight systems, information systems, and so on) which put hospital staff at predictable and preventable risk of making mistakes.

Some progress has been made. But this latest report shows how very far we have to go. A 14% reporting rate is absolutely dreadful, particularly because this is the report-rate for events that actually harmed Medicare patients. The IOM's goal was that not only harmful errors, but also "near-misses"--events that could have harmed patients, but luckily didn't--should be reported.

The Inspector General recommends that the government establish a list of reportable events, so that there's clarity about what needs to be reported and what doesn't; and that CMS (the Medicare agency) cooperate with accrediting bodies like the Joint Commission to establish review of hospital reporting procedures. Accrediting bodies currently tend to concentrate on what's done with reported information, rather than on the accuracy and breadth of the reporting process itself. That clearly needs to change.

Hepatitis C Vaccine Success and Chimpanzees

This article from Science Translational Medicine shows excellent results in a phase-1 trial of a new hepatitis C vaccine. This is a huge deal: hepatitis C infects 170 million globally, and causes a great deal of the world's liver damage. It kills more people in the US annually than HIV/AIDS.

The new vaccine was developed using chimpanzees as research subjects. I submit that this is exactly the sort of research for which the IOM's recent report on use of chimps in research left room. But I submit, also, that there aren't many more examples of this sort.

More on Chimps in Research

Now Francis Collins says NIH will abide by the IOM consensus committee's guidelines about use of chimps in biomedical and behavioral research. That was fast!