The OIG report, “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries[i]” has made quite a splash. Of course, the Center for Patient Safety is excited that it recommends increased participation with Patient Safety Organizations. But the report is a treasure trove of good information that can help to support safety efforts and QAPI program development.
The report found that 15% of Medicare SNF residents have preventable adverse events that cause greater than temporary harm. In addition, 11% of residents had temporary harm. The OIG used a trigger tool to help them identify medical records that reflected adverse events. The report contains a good discussion of trigger tool methodology.
Administrators and directors of nursing should consider reading the report, which is less scary than it looks at first blush. Here are some impressions:
- There is one clear limitation to the report. First, the OIG only looked at Medicare residents in the first 30 days of their stay, and then only looked at the first 30 days of care. This probably minimized the number of events they found.
- On the other hand, it has some other powerful information, both in the data it contains and the light it sheds on HHS’ (and CMS’) thinking about adverse events, Patient Safety Organizations and QAPI.
- The trigger tool itself and the description of its use can shed light on how to identify those unreported things in your home that surveyors will probably be looking for. This supports QAPI’s requirement to identify areas for improvement.
- The description of how the authors and their physician experts distinguished preventable and non-preventable events offers tremendous insight into how providers can evaluate and document the preventability their own events. For example, the report did not consider pressure ulcers preventable if all recommended evidence-based care was delivered or attempted, AND the ulcer developed anyway due to co-morbidities that made evidence-based care difficult to provide or ineffective.
- LTC providers need to improve identification and reporting of adverse events so that they can be studied and prevented. The report recommends participation with Patient Safety Organizations to help accomplish that goal, and to allow for broader study and learning.
- CMS needs to develop methods to encourage and the identification of events and the implementation of improvements. Expect this to be a survey focus going forward. The detailed information in the report about events it identified
The report is available at https://oig.hhs.gov/oei/reports/oei-06-11-00370.asp. The trigger tool is included as an appendix in the report. More information about the Center for Patient Safety’s Long-Term Care PSO services can be found at www.centerforpatientsafety.org/ltc-pso.