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Adverse Events in Long-Term-Care Hospitals

Amy Ashcraft, Deputy Regional Inspector General in the Office of Evaluation and Inspections in Dallas, is interviewed by Melissa Rumley, a public affairs specialist in Washington, D.C.

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Melissa Rumley (MR): An adverse event is harm to a patient resulting from medical care or an omission of necessary care. These events threaten patients' health and drain the Medicare program's resources. I'm Melissa Rumley, and welcome to the HHS-OIG's podcast.

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MR: OIG explores instances of harm in the report Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries. Long-term-care hospitals provide continued care for inpatients after their stays in traditional acute-care hospitals end. Patients are often very ill often and battle with multiple acute or chronic conditions. Amy Ashcraft, a Deputy Regional Inspector General for the Office of Evaluation and Inspections in Dallas, joins me via phone to discuss the report. Amy, thank you for sharing your insights.

Amy Ashcraft (AA): Thank you. It's nice to be here.

MR: Amy, Can you begin with explaining why OIG completed this review?

AA: We started this work in 2008 as a response to the Tax Relief and Healthcare Act of 2006. There was a Congressional mandate for us to look at the incidence of adverse events in acute-care hospitals. So we decided to expand into a series of work looking at additional environments in post-acute care. We have conducted incidence reports on skilled nursing facilities, inpatient rehab hospitals, and this is the final in the series: long term acute-care hospitals.

MR: Why has OIG continued these evaluations of adverse events?

AA: These events impact patient lives, often causing pain, and, for some patients, it even lead to their deaths. Additionally, these events have a financial cost to Medicare and to providers. The more we know about adverse events, which are most common, and which have the most significant impact on beneficiary health, the more we can educate providers to use strategies to reduce events.

MR: In the report, OIG makes a distinction between adverse events and temporary harm events. They are both types of patient harm, but can you explain the differences for our listeners?

AA: AA: We rank events based on the impact to the patient and the cost to the providers. Temporary harm events are the lower-level events, and they are events that were rectified relatively quickly and did not cause lasting harm to the patient. But if the event led to the patient needing a higher level of care, a longer stay in the facility, or resulted in permanent harm to the patient, we term it an adverse event.

MR: Thank you for the clarification. Can you now briefly describe OIG's findings?

AA: We found that 21% of Medicare beneficiaries experienced adverse events, and an additional 25% experienced temporary harm. So combined, 46% of the beneficiaries experienced some kind of harm that affected their medical care. And that rate is significantly higher than we found in other care settings. This is probably related to longer lengths of stay and more opportunities for harm to occur.

MR: According to the report, 54% of adverse and temporary harm events were clearly or likely preventable, while much of the remainder were clearly or likely not preventable. What is the significance of this finding?

AA: We believe it's important to track both preventable and not preventable events. In combination, they give us the best indicator of patient experience. With preventable events, we think those are important because they can be true indicators of the quality of care in a particular organization. They're used as a barometer to measure quality. Currently not preventable events tell us something else. They tell us where the problems occur that may be better rectified in the future. When we focus on both preventable and not preventable events, we can identify where the greatest degree of harm is occurring.

MR: So you have explained the importance of evaluating these harm events. What are OIG's recommendations for improvement?

AA: We're asking two federal agencies responsible for the oversight of adverse events and patient safety, the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, to work together to create a list of adverse events that can be used to educate providers, including letting them know the broad range of events that occur in LTCHs as well as the events most likely to occur in LTCHs. We are also asking the Centers for Medicare and Medicaid Services to share that information using their existing outreach practices to providers, including the definition of adverse events and how to use best practices to improve patient safety.

MR: Amy Ashcraft, of the Office of Evaluation and Inspections, thank you for your time.

AA: Great. Thank you for having me.

MR: For more information, visit

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