The OIG Says Your Adverse Events Were Clearly Preventable

A study conducted by the Office of the Inspector General (OIG) from 2008-2012 identified that an estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. They attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care.

Adverse Events Identified Among Medicare SNF Residents

This is how the adverse events broke down, by category types.

Events Related to Medication: 37%

• Medication-induced delirium or other change in mental status: 12%
• Excessive bleeding due to medication: 5%
• Fall or other trauma with injury secondary to effects of medication: 4%
• Constipation, obstipation, and ileus related to medication: 4%
• Other medication events: 14%

Events Related to Resident Care: 37%

• Fall or other trauma with injury related to resident care: 6%
• Exacerbations of preexisting conditions resulting from an omission of care: 6%
• Acute kidney injury or insufficiency secondary to fluid maintenance: 5%
• Fluid and other electrolyte disorders (e.g., inadequate management of fluid): 4%
• Venous thromboembolism, deep vein thrombosis (DVT), or pulmonary embolism (PE) related to resident monitoring: 4%
• Other resident care events: 14%

Events Related to Infections: 26%

• Aspiration pneumonia and other respiratory infections: 10%
• Surgical site infection (SSI) associated with wound care: 5%
• Urinary tract infection associated with catheter (CAUTI): 3%
• Clostridium difficile infection: 3%
• Other infection events: 5%

(The percentages within the three categories don't sum to 100 percent because of rounding.)

Interesting to note, in 2 of the 3 categories of Adverse Events, “Falls or other trauma with injury” are listed. So if you go back to the opening paragraph of this article, the findings from the OIG indicate that 59% of these incidents were clearly or likely preventable. Hmmmm, so 59% of falls with injuries may be “clearly or likely preventable”?

What is also interesting is that the study was performed using a team of physicians conducting retrospective medical record reviews. This seems a little like the proverbial Monday morning quarterbacking. It's always easier to identify causative factors, deficient practices, etc. after the fact and much more challenging to predict adverse outcomes.

Time to Rethink Your Processes

So what are we to do and where do we start? You may be tired of hearing “root cause analysis”—however, it may be time to evaluate your internal processes. None of us has a crystal ball to predict which residents will sustain a fall with injury, but our experience in managing frail elders does give us an edge. Maybe it's time to start the process before the resident even steps into your center!

Are you looking at preadmission reports from the hospital? Are you reviewing the medications and their impact on the resident’s sensorium (not just a PPS/reimbursement view)? What about lifestyle choices and previous incidents? I’m often told, "We don’t have time. If we don’t accept a referral quickly, the hospital will send the referral to someone else." If the OIG is looking at these outcomes, you may want to change your “heads in the beds” philosophy and accept the referrals you are able to safely care for.

Bring on the Crystal Ball

There is an inexpensive, quality option designed to assist in the process of trending, tracking, and root cause analysis. QA Reader is a web-based incident tracking dashboard that can provide your team with real-time resident-, unit-, and community-specific reports. QA Reader requires no software investment AND no additional data entry—just a button click to upload your incident report.

As a bonus, for no additional charge, an Evolucent risk manager will provide real-time feedback and recommendations for all triggered events. Think of the time your team is spending on data entry, trending, identifying new interventions, etc. Couldn't this time be better spent managing those resident’s at risk for falls and injuries? Absolutely!

Next Steps