Event Reporting in Aging Services
July 18, 2022 | Aging Services Risk Management
The prevalence of adverse events in long-term care settings is a primary driver of the need for effective reporting and response. For example, a 2014 study by the Department of Health and Human Services' Office of Inspector General (OIG) found that an estimated 22% of Medicare beneficiaries experienced adverse events in skilled nursing facility stays of 35 or fewer days; the same study also reported that an additional estimated 11% of patients experienced temporary harm events. Physician reviewers found 59% of the events "clearly or likely preventable." (OIG) It has been estimated that approximately 8 million adverse events occur annually in nursing homes. (Wagner et al.)
The human and organizational costs of adverse events are staggering, with estimates of preventable errors in the United States ranging from $17 to $29 billion per year in healthcare expenses, lost worker productivity, and disability. (Hoppes and Mitchell) The 2014 OIG study found that follow-up hospitalization costs related to adverse and temporary harm events in skilled nursing facilities totaled an estimated $2.8 billion per year. (OIG)
Several challenges associated with the long-term care environment have been identified as contributing to the prevalence of adverse events in this setting, among them resident frailty, complex needs of residents, insufficient organizational resources, and frequent transitions of residents between settings (e.g., rehospitalization). (Vogelsmeier)
Despite the undisputed prevalence of adverse events and near misses, underreporting is a significant concern and compliance varies among different groups of reporters. Although a variety of stakeholders are prospective reporters, including physicians, nurses, pharmacists, support staff, patients, and families, there are notable differences in who actually reports, and at what frequency. Researchers have found that most reports are submitted by nursing staff, who believe that safety reporting is one of their job responsibilities; pharmacists are also frequent reporters for medication-related events. However, physicians and medical residents, who are in the position to have intimate knowledge of events and their sequelae, tend to be less familiar with what and how to report, and may believe that reporting is not part of their job; therefore, they typically contribute a very small fraction of reports. (Heavner and Siner; Mansfield et al.)
Research has also shown that fear of liability and organizational and managerial barriers exist, and staff members are often apprehensive about punitive and adversarial approaches taken by employers. (Naveh...