Adverse events in post-acute care: the Office of the Inspector General's report.

Others (Falls, omission of care, dehydration, DVT) 37% Between 2008 and 2012, the Office of the Inspector General (OIG) examined the prevalence and causes of adverse events in hospitals (http://oig.hhs.gov/oei/reports/oei-06-09-00092.pdf). These suggested that 27% of all Medicare beneficiaries who were hospitalized experienced an adverse event. They determined that one-half of the events were preventable and that they cost Medicare an extra $4.4 billion annually. In February 2014, the OIG released a report examining a selected random sample of persons admitted from 1e35 days to a skilled nursing facility with the end date in August 2011 (http://oig.hhs.gov/ oei/reports/oei-06-11-00370.pdf). Their results were similar to the hospital data (Table 1) with 22% having an adverse event and 11% a temporary harm. They determined that 59% were preventable. They estimated that these adverse events extrapolated over a year cost the United States $2.8 billion. Based on their finding, they recommend a need to increase awareness of nursing home safety and methods to reduce potential harms. They also recommended that the Centers for Medicare and Medicaid Services (CMS) instruct state agency surveyors to look at nursing home practices to reduce adverse events. These findings are at first glance not that surprising based on the numerous articles in the Journal over the last few years concerning adverse events in long-term care.1e17 A major negative outcome was transfer back to hospital and it is hoped that the CMS’ championing the Intervention to Reduce Avoidable Acute Care Transfer (INTERACT) or other transition programs will help to reduce these adverse effects.7,9,14,18e27 Certainly having an advanced practice nurse or medical director fulltime in long-term care would be very advantageous.28,29 An important component of the long-term care fix is the hospitals. Notes received from the hospital are on the whole excessive, may fail to note medication changes on discharge, often do not address geriatric syndromes or the reasons for specific treatments, and may reach the nursing home physician late or not at all. The OIG recommendations will clearly lead to all nursing homes having a special committee to examine all adverse reactions in postacute care and especially those that result in returns to hospital within 30 days. Based on the OIG report, there is clearly a set of low hanging fruit. An extensive pharmacy review of medications needs to be done on the day of admission. This should focus on whether drugs are likely to