Report Finds Most Errors at Hospitals Go Unreported New York Times

" . . estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.”

Adverse events include

• medication errors,

• severe bedsores,

• infections that patients acquire in hospitals,

• delirium resulting from overuse of painkillers and

• excessive bleeding linked to improper use of blood thinners.

Reasons for not reporting the error included:

• employees do not recognize “what constitutes patient harm”

• do not realize that particular events harmed patients

• employees assumed someone else would report the episode

• they thought it was so common that it did not need to be reported

• “suspected that the events were isolated incidents unlikely to recur.”