Health system leaders have built increasingly sophisticated infrastructure for tracking and improving patient safety outcomes. Yet, a visibility gap remains that data alone can’t close: the near misses, workarounds and bedside observations that never make it into the reporting pipeline at all.
“Absence of harm does not equate to the presence of safety,” Amrita Gupte, MD, chief medical officer at Mount Sinai Queens, part of New York City-based Mount Sinai Health System, said during Becker’s 16th Annual Meeting. “We see just the tip of the iceberg. There are so many near misses and great catches that don’t get reported — and we lose that opportunity to learn from those incidents.”
While it’s difficult to quantify the true toll of near misses and any potential underreporting, federal data suggests the gap between what gets documented and what actually happens is significant — even for actual harm events.
A 2025 report from HHS’ Office of Inspector General found hospitals failed to capture 49% of harm events. About 46% of these incidents were not captured because staff did not consider them to be patient harm, but rather known complications or side effects.
The same blind spot can extend beyond reporting culture into how health systems monitor newly deployed technology, according to Dr. Gupte.
“We don’t do a good job measuring the workarounds,” she said. A governance committee can approve a tool, implementation can go smoothly and leadership can see nothing alarming in the data, even while the tool is quietly generating unintended consequences — such as alarm fatigue or workflows that add clicks — that no one is tracking.
The takeaway for clinical executives isn’t to distrust the data. It’s to treat a quiet dashboard or smooth technology rollout as a question rather than an answer. If the numbers look clean and nothing is coming through the reporting pipeline, the more productive response may be to ask what’s not being said, and why.
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