Regulatory Focus on Adverse Events

Regulatory Focus on Adverse Events

Office of the Inspector General

In 2014, the Office of the Inspector General released a report on Adverse Events in Skilled Nursing Facilities—National Incidence Among Medicare Beneficiaries. (Link to full report “OIG Report SNF”—Attached in Email)

Summary of OIG Report Findings:

  • Approximately one in five Medicare SNF residents experienced adverse events during a nursing home stay with 2.6% of the residents experiencing more than one adverse event.
  • More than 50% of the residents that experienced adverse events returned to the hospital.
  • Physicians reviews determined that 59% of the adverse events and temporary harm events were clearly or likely preventable.

Summary of OIG Recommendations:

  • Increase awareness of nursing home safety and seek to reduce harm through methods used to promote hospital safety efforts including collaboration to create and promote a list of potential nursing home events.
  • Instruct State Agency Surveyors to review nursing home practices for identifying and reducing adverse events.

CMS Memorandum on Medication-Related Adverse Events in Nursing Homes (Ref: S&C: 15-47-NH)

In July 2015, CMS released a memorandum announcing a pilot program–Focused Survey on Medication Safety Systems and released the CMS Adverse Drug Event Trigger Tool making the tool available to State Agency Surveyors for all types of surveys and encouraging nursing home operators to utilize the tool to conduct an internal quality assurance assessment.

In an effort to assist members in their quality assurance efforts, PHCA has created individual Adverse Drug Event Trigger Worksheets on each medication safety system topic outlined in the CMS Adverse Focused Survey on Medication Safety Systems and Adverse Drug Event Trigger Tool.

Medication-Related Adverse Events in Nursing Homes

Adverse events related to high risk medications can have devastating effects to nursing home residents. Proper management of high risk medications represents a serious challenge for nursing homes, and merits close attention by top management and staff throughout the facility. In July 2015 CMS released the Medication-Related Adverse Events in Nursing Homes letter.

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