The Inspector General performed an in-depth review of adverse events on a subset of people receiving care. A summary of their findings and recommendations is as follows:
The Office of Inspector General (OIG) found that 21 percent of Medicare patients in Long-Term-Care Hospitals (LTCH) experienced adverse events, which are particularly serious instances of patient harm resulting from medical care. The four categories of adverse events include outcomes such as
- Prolonging a patient’s LTCH stay or necessitating transfer to another facility
- Requiring life-saving intervention
- Resulting in permanent harm
- Contributing to death
An additional 25 percent of patients experienced temporary harm events, harm that required medical intervention but did not cause lasting harm. The overall percentage of patients in LTCHs who experienced either type of harm (adverse events or temporary harm events) is 46 percent, higher than OIG found in hospitals (27 percent), skilled nursing facilities (33 percent), and rehabilitation hospitals (29 percent). Patient stays in LTCHs present more opportunities for harm events because the stays are longer, but the number of harm events per patient day was similar between LTCHs and other post-acute-care settings and lower than in non-LTCH acute-care hospitals. Over half of these adverse events and temporary harm events (54 percent of harm events) were clearly or likely preventable. Preventable harm events were often related to substandard care (58 percent) and medical errors (34 percent). Forty-five percent of harm events were found to be clearly or likely not preventable, often because the patients were highly susceptible to harm due to other health conditions or poor overall health.
The OIG had several recommendations as a result of these findings. In response to prior OIG work, the Centers for Medicare & Medicaid Services (CMS) and Agency for Healthcare Research and Quality (AHRQ) took important steps to raise awareness of adverse events and temporary harm events and to reduce harm in several inpatient settings. AHRQ and CMS should tailor their ongoing efforts to improve patient safety to address the specific needs of LTCHs. The OIG recommends that AHRQ and CMS collaborate to create and disseminate a list of potential harm events in LTCHs and that CMS include information about patient harm in its outreach to LTCHs. CMS and AHRQ concurred with the recommendations.