About 22% of Medicare beneficiaries experienced an adverse event during a post-hospitalization skilled nursing facility stay in fiscal year 2011, and the majority of these events were preventable, according to a newly released government report. Post-acute provider groups said many initiatives to lower this percentage already are underway.

Investigators with the Department of Health and Human Services Office of the Inspector General analyzed a sample set of 655 Medicare beneficiaries who had a SNF stay of 35 days or less. The data were screened by two panels, one of nurses and one of physicians. The investigators ultimately determined whether an adverse event had occurred, whether it could have been prevented, and what the associated costs to the Medicare program were.

An adverse event was defined as an incident of patient harm that extended the SNF stay, sent the beneficiary back to the hospital, required a life-sustaining intervention or resulted in death.

Of the 22% of post-acute SNF stays that involved an adverse event, nearly 60% of these events were clearly or likely preventable, the physician review panel found. Some of these adverse events were related to well-known risks in the post-acute setting, such as pressure ulcers, but others were not. For example, severe gastrointestinal bleeding due to anticoagulant overdose was an identified adverse event that is “not commonly associated with nursing homes,” the authors wrote.

Overall, 37% of adverse events were related to medications, 37% were related to resident care issues (such as incidents stemming from inadequate monitoring) and 26% were related to infections, the investigators determined.

Hospitalizations due to adverse post-acute events in SNFs cost the Medicare program $208 million in the period studied, the OIG estimated.

This analysis follows a report on hospitals, which found a similar percentage of adverse events, the inspector general’s office noted.

The Agency for Healthcare Research & Quality should collaborate with the Centers for Medicare & Medicaid Services to compile a list of potentially reportable events for nursing homes, to be used to educate staff about the “full range of resident harm,” the report recommends. Other recommendations included encouraging providers to report adverse events to patient safety organizations, and the adoption of new survey guidelines that would include assessing adverse event identification and reduction efforts.

CMS and AHRQ agreed with these recommendations, while long-term care provider groups tepidly offered support.

The report’s recommendations could further “strengthen our efforts,” said David Gifford, M.D., MPH, vice president of quality and regulatory affairs at the American Health Care Association/National Center for Assisted Living.  He noted nursing homes “unprecedented success” in recent years in improving quality.

LeadingAge said it supports reporting events to patient safety organizations, which would allow for adverse event tracking without the threat of punitive repercussions.

Otherwise, “it is virtually impossible to create that transparent environment of self-reporting that is necessary in a safety culture,” said Cheryl Phillips, M.D., the association’s senior vice president of public policy and advocacy.  LeadingAge disagrees with the OIG recommendation that surveys can “reduce adverse events,” she said.

“We have yet to see evidence that a punitive oversight process, that is built on fines and punishment, is a driver of excellence,” Phillips noted.

There has been a “lack of data” about incidents of harm in post-acute settings, noted AMDA-Dedicated to Long-Term Care, an association of medical directors and nursing home physicians. The OIG report should be a “springboard for a national discussion” on this issue, the association stated.