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OIG Report Finds Adverse Events Are Prevalent in Nursing Facilities
The Office of Inspector General of the Department of Health and Human Services issued a recent report on Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. The reort was conducted from 2008-12 and based on a review of 653 Medicare beneficiaries discharged from hospitals to SNFs for post-acute care, with stays of 35 days or less in the SNF.
The OIG found that 22% of these Medicare beneficiaries experienced adverse events during their SNF stays and an additional 11% experienced temporary harm. Of these events, 59% were considered preventable. Over half of the residents who experienced harm returned to the hospital for treatment.
The OIG determined that 37% of the adverse events were related to medication, while another 37% related to ongoing resident care and 26% related to infections. Medication-induced delirium or mental status changes (12%), and excessive bleeding due to medication (5%) were the two most common types of medication adverse events. Of the three types of adverse events, medication events were considered the most preventable with 66% of medication adverse events rated as preventable.
Overall, 24% of all the adverse events in this study were preventable medication-related events. But since all nursing home residents are required to have a monthly medication regimen review, doesn't this number seem rather high?
At first glance, yes. But two points to keep in mind. Remember that all the residents in this study were post-acute care residents and the vast majority were present in the facility for less than one month. So many or most of these residents probably did not receive the traditional comprehensive on-site review by a consultant pharmacist. Their admission medication orders may have been screened via FAX but lab tests and other parts of the medical record may not have been available to the pharmacist at the time of admission.
Second, transitions of care are the highest risk time--when errors and problems are most likely to occur. So it is not a surprise that a short-stay population moving from hospital to nursing facility is going to be more at-risk than a more stable long-term population of traditional nursing home residents.
Despite the limitations in methodology of the OIG study, the findings may be an indication that room for improvement still exists in the care of this vulnerable population.
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