Nearly half of Medicare patients in long-term care hospitals experienced adverse or temporary harm events during their stays.
That’s among the findings of the HHS Office of Inspector General, which conducted a two-stage medical record review using physician reviewers to identify adverse events and temporary harm events in the sampled records.
One in five Medicare patients (21 percent) experienced adverse events during their stays in LTCHs, while 25 percent of Medicare patients in LTCHs experienced temporary harm events.
“The incidence rates for adverse events and temporary harm events include both preventable and not preventable events, but physician reviewers also assessed each event to determine whether it could have been prevented,” states the OIG report. “Using the documentation in the medical records, they determined that over half of adverse events and temporary harm events (54 percent) were clearly or likely preventable and that most of the remaining events (45 percent) were clearly or likely not preventable.”
Physician reviewers determined that more than half (58 percent) of preventable events affecting Medicare patients in LTCHs involved clinicians’ providing appropriate treatment or preventive care—but in a substandard way—while a little more than a third (34 percent) related to errors in medical judgment, skill and management.
“Our physician review of medical records found that many events were the result of substandard care or medical errors,” concludes the OIG’s report. “They also found that Medicare patients in LTCHs were particularly susceptible to some types of harm.”
The OIG recommended that the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services 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 the hospitals.
AHRQ and CMS concurred with the OIG’s recommendations. “Both agencies responded that they will work collaboratively to create and disseminate a list of potential adverse events in LTCHs,” states the report.