One of every seven hospitalized Medicare beneficiaries experiences adverse events while hospitalized, according to a new study from the U.S. Department of Health and Human Services' Office of Inspector General, released Tuesday.

The OIG study looked at a random sample of 780 Medicare beneficiaries who were discharged during the month of October 2008. Approximately 135,000 beneficiaries experienced adverse events during their stay, ranging from temporary harm to death, according to the report.

"The findings in the report are consistent with previous studies but are nonetheless disturbing," wrote Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality in a letter accompanying the study. "They confirm that adverse events continue to affect hospital inpatients at an alarming rate, and that the types of events that occur vary widely."

Physician reviewers of the data found that 44 percent of the events "were clearly or likely preventable," and the preventable events were most commonly associated with "medical errors, substandard care, and a lack of patient monitoring and assessment," stated the report.

Medicare lost an estimated $324 million in October 2008 to hospital care associated with adverse and temporary harm events to the hospitalized beneficiaries.

Among proposed recommendations in its report, OIG called on the Centers for Medicare and Medicaid Services and AHRQ to enhance their patient safety efforts, implement periodic measuring mechanisms of adverse events incidence rates, and for CMS to offer further incentives for hospitals to reduce the rate.

In a letter accompanying the study, Dr. Donald Berwick, CMS administrator, wrote the agency is "an engine for innovation across health care" and that its new Center for Medicare and Medicaid Innovation will address issues such as adverse events.

"While the report characterizes CMS as an oversight entity and the nation's largest health payer, CMS is also actively transitioning from serving solely as a regulator and passive payer of health care services to an agency that fully supports public health goals as an active payer of high quality and efficient care," Berwick said.

AHRQ and CMS both concurred with the report's recommendations.

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