​Twenty-one percent of Medicare patients in long-term care hospitals experienced adverse events, and an additional 25% experienced temporary harm events, according to the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services. In addition, over half of these adverse and temporary harm events were clearly or likely preventable, according to a November 2018 report. OIG examined the medical records of 587 Medicare beneficiaries admitted to long-term care hospitals in March 2014. The adverse events were divided into four categories: events that prolonged a patient's stay or necessitated a transfer to another facility; events that required lifesaving intervention; events that contributed to or resulted in permanent harm; and events that contributed to or resulted in death. Approximately 54% of adverse or temporary harm events were found to be clearly or likely preventable, with 58% and 34% related to substandard care and medical errors, respectively. Based on the report, OIG recommended that the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services tailor their efforts to improve patient safety to address the needs of long-term care hospitals, and that the two groups collaborate to disseminate a list of potential harm events. In addition, OIG recommended that CMS include information about patient harm in its outreach to long-term care hospitals.

HRC Recommends: The OIG report notes that the estimated 46% harm rate in long-term care hospitals surpassed the 27% rate found in hospitals, the 33% rate found in skilled nursing facilities, and the 29% rate found in rehabilitation hospitals. Clear communication, comprehensive assessment, effective monitoring, and empowered care providers are needed to reduce risk in this care area.