From 2008-2012, we conducted a series of studies about hospital adverse events, defined as harm resulting from medical care. This work included a congressionally mandated study to determine a national incidence rate for adverse events in hospitals. As part of this work, we developed methods to identify adverse events, determine the extent to which events are preventable, and measure the cost of events to the Medicare program. This study continues that work by evaluating post-acute care provided in skilled nursing facilities (SNF). SNF post-acute care is intended to help beneficiaries improve health and functioning following a hospitalization and is second only to hospital care among inpatient costs to Medicare. Although various healthcare stakeholders have in recent years paid substantial attention to patient safety in hospitals, less is known about resident safety in SNFs.

How We Did This Study

This study estimates the national incidence rate, preventability, and cost of adverse events in SNFs by using a two-stage medical record review to identify events for a sample of 653 Medicare beneficiaries discharged from hospitals to SNFs for post-acute care. Sample beneficiaries had SNF stays of 35 days or less.

What We Found

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. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011.

Source: United States Department of Health and Human Services. (2013). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries. Retrieved fromhttp://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf(Links to an external site.)

1. Placing yourself in the position of the Nursing Home Administrator, what would you expect CMS to determine SNFs to do as a result of the findings?