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Adverse Events in Nursing Homes

The Centers for Medicare & Medicaid Services (CMS) has compiled information and resources related to adverse events in nursing homes to assist providers to identify, track, and systematically investigate adverse events that have occurred, as well as develop and implement systemic interventions that will help prevent adverse events. CMS will continue to add resources and tools as they become available.

Adverse Events in SNFs: National Incidence among Medicare Beneficiaries, Department of Health and Human Services, Office of Inspector General report OEI-06-11-00370

In February 2014, the Office of Inspector General (OIG) released its report Adverse Events in SNFs: National Incidence among Medicare Beneficiaries.   It reported that one in three skilled nursing facility (SNF) beneficiaries were harmed by an adverse event or temporary harm event within the first 35 days of their skilled stay. The OIG determined that nearly 60 percent of those events were preventable.

Click here to access the OIG report - Adverse Events in SNFs:  National Incidence among Medicare Beneficiaries

AMDA – The Society for Post-Acute and Long-Term Care Medicine: Quality Prescribing

In response to both the OIG report on Adverse Events and the National Action Plan for Adverse Drug Event Prevention, AMDA developed a workgroup to produce simple, actionable guidance on three targeted classes of medications: Anticoagulants, Diabetes agents, and Opioids.

Click here to access AMDA’s Quality Prescribing Webpage

CMS Call to Action: Raising Awareness for Reducing Adverse Events in Nursing Homes

In response to the OIG report on adverse events in skilled nursing facilities, CMS launched a year-long campaign to create strategies and actions among CMS and its partners to raise awareness of, and reduce adverse events in nursing homes.

Click here to see a summary of the Call to Action Campaign

CMS Adverse Drug Event Trigger Tool

Of all the events identified in the OIG report, 37 percent were related to medication.  The second most frequent cause of medication related adverse events was excessive bleeding related to anticoagulant use causing harm ranging from hospitalization to death.
These findings are further supported by Propublica data reported in a recent Washington Post article which stated, “…from 2011 to 2014, at least 165 nursing home residents were hospitalized or died after errors involving Coumadin or its generic version, warfarin1. It is clear that adverse events related to high risk medications continue to be pervasive with devastating effects to nursing home residents.”

During its collaboration with AHRQ, CMS began work to develop and test a Focused Survey on Medication Safety Systems that looks at nursing home practice around high-risk and problem prone medications, such as warfarin.  One of the foundational tools for the survey grew from the listing of potentially preventable adverse events.  CMS envisions this tool as a resource document containing necessary information for evaluating high risk medications.  It was designed to be a crosswalk that lists:

  • Common potentially preventable adverse drug events;
  • Risk factors related to those events;
  • Triggers – signs, symptoms, or clinical interventions which could indicate that the adverse drug event has occurred; and,
  • Probes which would assist surveyors in evaluating systems around high risk medications.

Click here to access the CMS Adverse Drug Event Trigger Tool

The Centers for Disease Control and Prevention’s (CDC) Infection Control Assessment Tool for Long-term Care Facilities (LTCFs)

The OIG report found that nearly one in three adverse events were related to infections. The CDC has developed a tool that is intended to assist in the assessment of infection control programs and practices in nursing homes and other long-term care facilities.

Click here to access the CDC’s Infection Control Assessment Tool for LTCFs.

 The CDC’s National Healthcare Safety Network:

The CDC’s National Healthcare Safety Network (NHSN) provides nursing homes and other long term care facilities with a customized system to track infections in a streamlined and standardized way. When facilities track infections, they can identify opportunities for prevention and monitor progress toward stopping infections. On the national level, data entered into NHSN by long term care facilities will help define the burden of infections in this setting and gauge progress toward national infection prevention goals.

Click here for more information on tracking infections using NHSN

Institute for Healthcare Improvement (IHI) Skilled Nursing Facility (SNF) Trigger Tool for Measuring Adverse Events

The IHI SNF Trigger Tool for Measuring Adverse Events was co-authored by IHI and the OIG.  This tool provides step-by-step instructions for using this methodology to identify adverse events in SNFs, guidance on designing a Trigger Tool review, and detailed descriptions of the Trigger Tool components. There is no cost to register on the IHI website in order to download the PDF.

Click here to access the IHI SNF Trigger Tool

National Action Plan for Adverse Drug Event Prevention

The Department of Health and Human Services’ National Action Plan for Adverse Drug Event Prevention provides a framework to minimize the occurrence of common, dangerous, and preventable adverse drug events related to anticoagulants, diabetic agents, and opioid medications.

Click here to access the National Action Plan for Adverse Drug Event Prevention

Potentially Preventable Adverse Events in Nursing Homes

In the report on adverse events, the OIG recommended that Centers for Medicare & Medicaid Services (CMS) collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop and promote a listing of potential events that occur in nursing homes to raise awareness of adverse events that harm to nursing home residents.  Using the OIG study, CMS and AHRQ worked together to create a list of the most common potentially preventable adverse events.

Click here to access a listing of Potentially Preventable Adverse Events

Acronyms related to Adverse Events

Click here to access a listing of acronyms related to Adverse Events in Nursing Homes

Adverse Events Tools and Resources

CMS will add resources and tools as they become available, which may assist nursing home providers to identify, track, and systematically investigate adverse events that have occurred; as well as develop and implement systemic interventions that will help prevent adverse events.

1Charles Ornstein, Popular blood thinner causing deaths, injuries in nursing homes. Washington Post, July 12, 2015,  http://www.washingtonpost.com/national/health-science/popular-blood-thinner-causing-deaths-injuries-in-nursing-homes/2015/07/12/be34f580-1469-11e5-89f3-61410da94eb1_story.html

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