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    Almost 60% of Patient Harm In SNFs Preventable, Says HHS IG Report

    A US Department of Health and Human Services (HHS) Inspector General's report says that nearly 60% of harm incidents experienced by patients in skilled nursing home facilities (SNF) are preventable, and that this gap in prevention resulted in hospitalizations that cost Medicare an estimated $2.8 billion in 2011. Among the preventable "adverse events" were falls, which the report related to both medication and resident care.

    The March 3 report (.pdf) from the HHS Office of the Inspector General (OIG) states that "Because many of the events that we identified were preventable, our study confirms the need and opportunity for SNFs to significantly reduce the incidence of resident harm events," and recommends that, among other things, the Centers for Medicare and Medicaid Services (CMS) direct its state facility surveyors "to review facility practices for identifying and reducing adverse events."

    The report focused on an analysis of 653 patients under Medicare who stayed in SNFs during the month of August, 2011, who began their SNF stay within 1 day after discharge, and whose stays in the SNF was 35 days or fewer. According to the report, 70% of the patients arrived at the SNF after hospitalization for nonsurgical treatment (most often septicemia or urinary tract infections), with the remaining 30% arriving after receiving surgery, usually hip or knee replacement.

    The study defined an adverse event as harm that resulted in "prolonged SNF stay or transfer to a hospital, permanent harm, life-sustaining intervention, or death." Events were classified by a panel of physicians after initial records screening by a panel of nurses led by a nurse practitioner. If evidence of an adverse event was identified by the nurse panel, the records were then reviewed by the physicians, who made a determination of whether the event was preventable. Researchers also analyzed "temporary harm events" that required medical intervention but did not cause lasting harm.

    According to the report, about 1 in 5 Medicare beneficiaries receiving post-acute care in SNF in August 2011 experienced an adverse event, and an additional 11% experienced a temporary harm event. Of those combined events, physician reviewers estimated that 59% were "clearly or likely preventable," and due to "substandard treatment, inadequate resident monitoring, and failure or delay of necessary care." The 59% preventable rate is an average of a 69% preventable rate for adverse events, and 46% preventable rate for temporary harm events.

    Among the IOG findings:

    • Of the preventable adverse events, 79% resulted in prolonged stay, transfer, or hospitalization; 14% required intervention to sustain life; and 6% resulted in or contributed to death
    • Harm related to medication was cited as a cause for 37% of the preventable events, with falls accounting for 4% of events in this category; harm related to resident care accounted for another 37% of preventable events, with falls making up 6% of that category; and 26% of preventable events were categorized as infection-related
    • Of the estimated $208 million spent by Medicare in August 2011 on all hospitalizations because of adverse events, $136 million was spent on hospitalizations associated with preventable events

    The report includes 2 major recommendations, both of which have been endorsed to greater and lesser degrees by CMS and the Agency on Healthcare Research and Quality (AHRQ). The bulk of the OIG recommendations focus on the development of lists of preventable events "to broaden and improve [SNF] staff understanding," the inclusion of preventable events in Quality Assurance and Program Improvement (QAPI) systems, and encouragement to SNFs to report adverse events to patient safety organizations (the only recommendation that received qualified agreement from CMS).

    The second major recommendation from the OIG was that CMS instruct state survey agencies "to include an assessment of adverse event identification and reduction in their evaluations of QAPI and [Quality Assessment and Assurance] compliance, and link related deficiencies specifically to resident safety practices." According to the report, CMS stated that activities under way to establish QAPI requirements for nursing homes "will include guidance for surveyors on how to evaluate nursing home efforts to identify and reduce adverse events."

    APTA provides physical therapists (PTs) and their patients and clients with education on exercise prescriptions for balance and falls prevention, a pocket guide on falls risk reduction (.pdf) and an online community where members can share information about falls prevention. In addition, APTA offers its members evidence-based resources on falls through PTNow as well as through PTNow ArticleSearch, its tool for access to current research works.The association's webpage on safe patient handling also includes information on how to patient and provider injury risk.


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