The World Health Organization (WHO) defines patient safety as “a framework of organized activities to reduce risks, lower the occurrence of avoidable harm, make errors less likely, and minimize their impact when they occur.” Over this past summer the HHS Office of the Inspector General (OIG) published three patient-safety reports. (Since 2008 the OIG has published at least 24 related studies.) One published in July found hospitals failed to capture half of harm events that occurred among hospitalized Medicare patients, few were investigated and even fewer led to hospitals making PS improvements. These findings were sadly unsurprising since the OIG previously found in 2008 that 27% of Medicare patients experienced harm during hospital stays, a decade later, or in 2018, still 25% experienced harm. In an July 24 OIG letter to CMS Administrator, Dr. Mehmet Oz, the OIG noted in part that while CMS and states require hospitals to publicly report just 15 of 94 harm events, hospitals reported only 5 of 15, or 5% of all 94 harm events. HHS has yet to publicly respond to the OIG’s recent reports much less recognize them. Dedicated podcast listeners may recall I’ve previously discussed patient safety in 2015, 2017 and in 2020.
A summary of the HHS OIG’s adverse events/patient safety work with a list of its publications can be found at: https://oig.hhs.gov/reports/featured/adverse-events/.
Information regarding Mr. Millenson is at: https://millenson.com/.
Mr. Millenson’s recent medical errors essay in Forbes is at: https://www.forbes.com/sites/michaelmillenson/2025/09/12/lessons-from-the-medical-error-that-orphaned-a-cabinet-secretary/.
