• ADVERSE EVENTS IN SKILLED NURSING FACILITIES: NATIONAL INCIDENCE AMONG MEDICARE BENEFICIARIES

    Saturday February 1, 2014

    From 2008-2012, the OIG conducted a series of studies about hospital adverse events, defined as harm resulting from medical care. This work included a Congressionally mandated study to determine a national incidence rate for adverse events in hospitals. As part of this work, they developed methods to identify adverse events, determine the extent to which events are preventable, and measure the cost of events to the Medicare program. This study continues that work by evaluating post-acute care provided in skilled nursing facilities (SNF). SNF post-acute care is intended to help beneficiaries improve health and functioning following a hospitalization and is second only to hospital care among inpatient costs to Medicare. Although various health care stakeholders have in recent years paid substantial attention to patient safety in hospitals, less is known about resident safety in SNFs.

    Because many of the events identified were preventable, our study confirms the need and opportunity for SNFs to significantly reduce the incidence of resident harm events. Therefore, the OIG recommends that the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) raise awareness of nursing home safety and seek to reduce resident harm through methods used to promote hospital safety efforts. This would include collaborating to create and promote a list of potential nursing home events-including events we found that are not commonly associated with SNF care-to help nursing home staff better recognize harm. CMS should also instruct State agency surveyors to review nursing home practices for identifying and reducing adverse events. AHRQ and CMS concurred with our recommendations.

    To read the complete OIG report, click on the attachment below.

    Adverse Events in SNF 2014

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