A published issue of the Joint Commission Journal on Quality and Patient Safety has opened the medical community's eyes to the fact that even though behavior health provider negligence is on the rise, it is being severely under-reported. In fact, only about one-third of the events that involve behavioral health patients hospitalized is reported.
Findings in the Veterans Health Administration medical centers
The report covered reviews of charts and incident reports in 40 behavioral health facilities that are part of the country's Veterans Administration medical center. To gather data, they drew from random sampling of discharges, which accounted for about 9 percent of the inpatient psychiatric patients during the year. Each report from the random draw was thoroughly reviewed and matched with incident reports for the same patients.
What the reviewers found was somewhat shocking. Only 37.4 percent of the events that the researchers found in the patient charts were reported in the facility's event reporting system. They even found that severe problems, such as events that ended up with harm to the patient had failed to be reported. These harmful events accounted for over 48 percent of the events in the patient charts, but many were not found when the event reporting system was cross-checked.
Why are patient events not being properly reported as they should?
There are often many barriers associated with event reporting that can cause facilities to not properly report events as they should. Some of the most common barriers that researchers feel are the biggest obstacle to effective reporting include:
- The culture of blame
- The perception that reporting will do nothing to promote change
What is concerning to researchers is that effective reporting is a necessary tool to help identify patient safety issues and work towards rectifying them. Other reports have reiterated this need for proper reporting in facilities. There have been cases of patients, who have a history of psychiatric illness, going to the emergency room and have had medical issues dismissed by it being inaccurately attributed to be an aspect of the psychiatric disorder, instead of the physical ailment that it was. This reinforces not only the need for proper reporting to maintain patient safety but also for the medical profession to obtain a better understanding of mental illness and how to properly treat patients who may have both a psychiatric and physical condition.
Recommendations from the report
From the research and reports, it has been recommended that the barriers to effective reporting and response, such as fear, time constraints, and cumbersome systems, need to be addressed and removed so that all healthcare systems can properly meet the needs and ensure the safety of patients with behavioral health issues. To do these healthcare facilities need to:
- Put an emphasis on detecting failures in the system instead of focusing on individual errors that resulted in events
- Provide timely and compassionate feedback when incidents do occur
- Provide a culture that promotes reporting as a necessary issue to properly care for patients
The lack of reporting can be particularly concerning for families with loved ones who seek treatment in behavioral health facilities. When a loved one is an inpatient, there is an expected level of care and safety that that patient is entitled to. When incidents go unreported, it not only compromises the care and safety of the patient but also the staff. If you have a loved one that suffers from behavioral health or psychiatric problems and you feel that their safety has been compromised due to a lack of proper reporting or process in a behavioral health facility, you don't have to remain silent. Contact legal counsel to determine if your loved one has suffered detrimental effects from improper reporting so that these issues will no longer be swept under the rug and your loved one will receive the safe and dutiful care they need for their treatment and recovery.