Preventable Nursing Home Mistakes Suffered by 22% of Patients: Report

A new government review suggests that nearly a quarter of all nursing home residents experience an adverse event and another 11% are harmed due to mistakes, most of which were preventable.  

In a report (PDF) published by the U.S. Department of Health & Human Services’ Office of Inspector General (DHHS-OIG) last month, researchers looked at information on adverse events affecting Medicare beneficiaries in hospitals from 2008 to 2012, where patients suffered harm resulting from medical care. The latest report on skilled nursing facilities (SNFs) is a breakout from that original study.

Preventable nursing home mistakes result in additional costs for Medicare, often leading to a nursing home or hospital receiving additional reimbursements for treating the damage caused. Reducing such events could result in large savings for the federal government.

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Researchers used the study to estimate the national incidence rate, the cost of such mistakes, and whether they could have been prevented. They found that 22% of Medicare beneficiaries suffered adverse events while in nursing homes, and another 11% were harmed temporarily during their time in such facilities, meaning that a third of all nursing home patients are affected by adverse events. About 59% of those medical mistakes were found to be certainly or most likely preventable.

The study found that more than half of those who were harmed by mistakes had to be hospitalized, costing Medicare $2.8 billion in 2011 alone.

The report calls for nursing homes to be made more aware of common adverse events, to make efforts to reduce nursing home neglect, and to use some of the same techniques used by hospitals to avoid preventable mistakes. Researchers also called on better encouragement of nursing homes to report adverse events to patient safety organizations.

“Because more than half of the adverse events that we identified were preventable, our study confirms the need and opportunity for SNFs to significantly reduce the incidence of events,” the report concludes. “This reduction in events and improved safety for post-acute residents would require a coordinated response to include both providers and overseers.”


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