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Transcript for audio podcast: Adverse Events in Skilled Nursing Facilities

From the Office of Inspector General of Department of Health and Human Services

[Lyndsay Patty] I am Lyndsay Patty, with the Office of Inspector General, speaking with Jeremy Moore, a senior analyst for our Office of Evaluation and Inspections, about the newest report in a major series about adverse events in health care facilities, with this report focusing on nursing homes. Jeremy, patient safety is such an important topic that affects families across America. Tell us how you got started.

[Jeremy Moore] Sure Lyndsay. We began our work about adverse events in response to a Congressional mandate. Congress directed the IG to determine how often Medicare patients are harmed from medical care, what we call "adverse events." Congress also asked us to determine the cost of these adverse events to the Medicare program.

[Lyndsay Patty] So what are some examples of adverse events?

[Jeremy Moore] They include health-care acquired infections, procedural complications, and medication errors.

[Lyndsay Patty] Can you tell us why you decided to look at nursing homes, specifically Skilled Nursing Facilities?

[Jeremy Moore] Absolutely. Medicare patients frequently go to Skilled Nursing Facilities to recover after a hospital stay. These nursing homes provide skilled nursing care and rehabilitation services to beneficiaries, so they are a critical part of the health care system. We've done earlier work on adverse events in hospitals, so extending this work to the Skilled Nursing Facility setting was a logical next step.

[Lyndsay Patty] These evaluations take a lot of time and work. How'd you go about it and what did you find?

[Jeremy Moore]: We arranged for physicians with expertise in adverse event detection to examine skilled nursing facility medical records. They found that 33 percent of Medicare residents experienced a harm event, ranging from serious events that caused permanent harm to less-serious events that caused only temporary harm. Nationwide, our findings suggest that, in one month, an estimated thirty-three thousand Medicare patients experienced serious problems at a skilled nursing facility.

[Lyndsay Patty] So did these events have a financial impact to Medicare?

[Jeremy Moore] Yes, these events cost Medicare a lot of money. We found that when adverse events occur in Skilled Nursing Facilities, they often result in a hospitalization. In our study, over half of the residents went to a hospital after an adverse event. On average, Medicare paid about $10,000 dollars for hospital stays tied to a skilled nursing facility adverse event.

[Lyndsay Patty] Wow, so what's the total cost to Medicare for these hospitalizations?

[Jeremy Moore] Well, if you add up all the hospital visits that resulted from adverse events, we estimate that Medicare paid just under $3 billion dollars, in one year.

[Lyndsay Patty] $3 billion dollars, plus the impact on residents lives. Were these harmful events caused by medical errors?

[Jeremy Moore] Some were caused by staff errors, but not all. Many preventable events happened largely because of substandard treatment, like not properly monitoring residents. Our physicians also found that many adverse events were not preventable because the residents were so fragile or they had very very complex cases. The big takeaway is that most of the harm in nursing homes can be avoided with better care, making a strong case for improved practices.

[Lyndsay Patty] What is the government doing to improve practices to reduce harm?

[Jeremy Moore] Great question Lyndsay. Government and nursing homes must continue improving patient safety. Fortunately, lots of good models exist. CMS is working to provide guidance to nursing homes on how to meet new quality assessment and performance improvement standards. Nursing homes will be required to collect and analyze quality data, like data on adverse events, to improve performance. And, the Agency for Healthcare Research and Quality, commonly referred to as AHRQ, has established best practices for health care facilities to report adverse events.

[Lyndsay:] And so what are Skilled Nursing Facilities doing to improve care?

[Jeremy:] Another great question. People within the nursing home industry, and those in academia, are definitely working to improve care in nursing homes. We're aware of efforts to help nursing home staff manage changes in residents' conditions to avoid hospitalizations and help hospitals safely transfer patients from hospitals to nursing homes.

[Lyndsay Patty] So give us a look ahead, do you have more work planned in this area?

[Jeremy Moore] Yes, we do. We are beginning a study that will examine how often adverse events occur in rehabilitation hospitals. We will again examine both the frequency and cost of harmful events.

[Lyndsay Patty] Thank you Jeremy, for sharing this important work on nursing home safety.

[Jeremy Moore] Thank you, Lyndsay.


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