Hospital ‘harm events’ slip through the cracks, HHS OIG finds

Modern Healthcare – Tuesday, July 29, 2025
By Bridget Early

Hospitals are falling short of federal and state harm reporting requirements, according to a report federal investigators published Tuesday.

Nearly half of hospitals surveyed failed to identify “harm events” among hospitalized Medicare patients in October 2018, according to the Health and Human Services Department Office of Inspector General. Even fewer of those occurrences were investigated, the OIG found.

“We determined that 16% (15 of 94) of harm events that hospitals identified and captured in their incident reporting or other surveillance systems were required to be reported externally per [Centers for Medicare and Medicaid Services] and/or state requirements,” the report says. “Yet, in our sample, hospitals reported only 5 of 15 captured events per these requirements. For the remaining 79 events not required to be reported externally, hospitals voluntarily reported 7 of those events for learning purposes.”

Hospitals told the OIG that they did not identify some harm events because staff did not consider them to be harmful, that it was not standard practice to capture them and that it was difficult to distinguish harm from patients’ underlying medical conditions, according to the report.

“When hospitals fail to identify and report harm events to the appropriate oversight entities, they stymie independent feedback needed to take corrective actions,” the OIG wrote. “The lack of such actions hampers system-level improvements that can prevent future harm from occurring.”

The OIG recommends stronger federal oversight. Regulators should establish standardized definitions of patient harm, instruct surveyors to assess compliance with Medicare quality programs and offer more detailed guidance to providers.

CMS and the Agency for Healthcare Research and Quality concurred with the recommendation on standardized definitions, and CMS also endorsed a suggestion that it assist hospitals with incident reporting systems. CMS did not weigh in regarding surveyor guidance.

In a separate report released Tuesday, the OIG identified gaps in CMS emergency preparedness protocols for hospitals, which the investigative agency concludes could undercut providers’ ability to navigate infectious disease outbreaks.

CMS could strengthen surveyor guidance and training, link hospital accreditation with the ability to care for all at-risk populations and encourage hospitals to prioritize mental health among frontline workers, according to the OIG. CMS agreed with those recommendations.

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