Why OIG Did This Review. In a series of reports from 2008 to 2016, OIG found that adverse events and temporary harm events are common, endanger patient health, and are costly to the Medicare program. In a 2010 study, OIG found that 27 percent of hospitalized Medicare beneficiaries experienced such events, costing Medicare approximately $4.4 billion a year. OIG then expanded on this work by examining post-acute-care settings, finding that 33 percent of Medicare beneficiaries in skilled nursing facilities and 29 percent of Medicare beneficiaries in rehabilitation hospitals experienced harm. This report builds upon this prior work, focusing on Medicare stays in LTCHs. How OIG Did This Review OIG reviewed medical records for 587 Medicare beneficiaries admitted to LTCHs in March 2014 to establish a national incidence rate of adverse events and temporary harm events. The review was conducted in two stages. In the first stage, nurses screened records for possible harm events. In the second stage, physicians conducted a comprehensive review of the records flagged as containing possible harm events. Physicians identified the harm events, determined the level of harm, whether the events were preventable, and the factors that contributed to the events. What OIG Found. The Office of Inspector General (OIG) found that 21 percent of Medicare patients in LTCHs 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; and contributing to death. (Five percent of Medicare patients in LTCHs experienced adverse events that contributed to or resulted in their deaths.) An additional 25 percent of patients experienced temporary harm events, which are patient 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. What OIG Recommends. 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. We recommend 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 our recommendations.
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