HHS OIG Finds Patient Harm in 25% Of Medicare Patients

The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) just released a landmark study reporting that 25% of Medicare patients suffer patient harm and that 43% of those, or about 12% of the total, are preventable.

This report, released as a 10-year anniversary follow-up of their previous 2012 report, “Hospital Incident Reporting Systems Do Not Capture Much Harm,” provided significant detail on the trigger-based adverse event identification method used and called upon CMS and AHRQ to do more to address the patient harm issue.

Beyond the foundational clinical problem, the HHS OIG calculated that, looking only at certain populations, the cost of harm to Medicare is approximately $9.6B per year.

The HHS OIG report will raise awareness further on the extent of patient harm, its financial cost, and accelerate further CMS and regulatory efforts – particularly around the use of EHR data to measure and manage patient suffering in the United States. 


Pascal suggests the following to be the key takeaways:

  1. Significant Suffering.  Harm is a serious problem that has not been adequately addressed.  A quarter of patients suffer harm, and 12% of the total are preventable.  These are statistics until your loved one (or you) become one of the over 1 in 10 patients who suffers preventable harm or 1 in 4 that suffers at all.
  2. Financially Costly.  Both public and private payors should do more to reward safe care, first to protect their citizens/consumers and, second, to reduce their costs.  CMS’ current policies, according to the HHS OIG, miss 95% of patient harm and, according to the OIG,  “have limited effectiveness in broadly promoting patient safety.”  
  3. Chart Review Methodology.  HHS OIG used a two-stage “gold standard” chart review methodology, whereby clinical triggers were used to identify potential adverse events, which were then reviewed by nurses and authenticated by physicians — the same method used by Pascal which we apply for all harm all the time for all patients that we enable clients to scale using the Virtual Patient Safety (VPS) solution.

Overall, Pascal expects this landmark report to accelerate the field’s embrace of a method that finds the most patient harm and related cost and reduces both — just as health systems in recent years have demonstrated is possible.

Findings of Patient Harm

Taking a deeper dive, the most important summary findings were;

  • 25% of patients suffer harm
  • Physician reviewers determined that 43% of those patients, or 12%, were preventable, which led to longer hospital stays, permanent harm, life-saving intervention, or death
  • 13% of patients experienced temporary harm events 

The categories of patient harm events were related to:

  • Medication (43%), such as patients experiencing delirium or other changes in mental status 
  • Patient care (23%), such as pressure injuries 
  • Procedures and surgeries (22%), such as intraoperative hypotension
  • Infections (11%), such as hospital-acquired respiratory infections

On preventability, the HHS OIG concluded that:

  • 43% of harm events were preventable, “with preventable events commonly linked to substandard or inadequate care provided to the patient”
  • This preventability determination did not apply if clinicians followed policies and procedures 

CMS maintains two lists of hospital acquired conditions (HACs), the HAC Reduction Program list and the Deficit Reduction Act HAC list.  CMS policies create payment incentives for preventing harm by reducing payment for certain HACs.  However, as the OIG points out:

  • Limited Effectiveness.  “Because the policies use narrowly scoped lists of HACs and employ specific criteria for counting harm events, they have limited effectiveness in broadly promoting patient safety.”    
  • Limited Scope.  “The lists did not cover most of the harm events that patients in our study experienced.  Of the harm events we identified, only 5 percent were on CMS’s HAC Reduction Program list and only 2 percent were on CMS’s Deficit Reduction Act HAC list.”  [emphasis added]


The HHS OIG made seven recommendations, which included three to CMS and four to the U.S. Agency for Healthcare Research and Quality (AHRQ):

To CMS, the OIG recommended (copied verbatim): 

  1. Update and broaden its lists of HACs to capture common, preventable, and high-cost harm events;
  2. Explore expanding the use of patient safety metrics in pilots and demonstrations for health care payment and service delivery, as appropriate; and
  3. Develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm.  

To AHRQ, the OIG recommended (also copied verbatim):

  1. With support from HHS leadership, coordinate agency efforts to update agency-specific Quality Strategic Plans; 
  2. Optimize use of the Quality and Safety Review System, including assessing the feasibility of automating data capture for national measurement and to facilitate local use; 
  3. Develop an effective model to disseminate information on national clinical practice guidelines or best practices to improve patient safety; and 
  4. Continue efforts to identify and develop new strategies to prevent common patient harm events in hospitals.