Adverse Events:

Surveillance Systems for Adverse Events and Medical Errors

T-HEHS-00-61: Published: Feb 9, 2000. Publicly Released: Feb 9, 2000.

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Pursuant to a congressional request, GAO discussed its report on issues related to adverse medical events in the nation's health care system.

GAO noted that: (1) the results of GAO's work have important implications for addressing adverse medical events including the design of surveillance systems to detect adverse events and medical errors; (2) while adverse events have been recognized as a serious problem, the full magnitude of their threat to the health of the American public is unknown; (3) gathering valid and useful information about adverse events is extremely difficult; (4) all systems that rely on health care providers to take the initiative to make a report--known as passive or spontaneous reporting systems--have serious limitations; (5) this is true whether or not providers are legally required to report adverse events; (6) both mandatory and voluntary spontaneous reporting systems share this limitation; (7) many of the injuries patients suffer as a result of medical treatment do not stem from errors but reflect the inherent risks of treatments that are administered correctly; and (8) it can be difficult both to identify these adverse reactions and distinguish them from medical errors or from the course of a patient's underlying illnesses.

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