Event Reporting and Response
January 29, 2016 | Aging Services Risk, Quality, & Safety Guidance
Resident safety initiatives promote the collection of accurate data so that objective information can be imparted to affected residents and the usefulness of the data for preventing similar future events can be increased. In conjunction with other managers, risk managers must conduct event investigations in order to identify the factors contributing to the occurrence of reported events and to support efforts to eliminate and control those factors. Underreporting of adverse events continues--- despite state laws mandating reporting and the federal Patient Safety and Quality Improvement Act (PSQIA), which incentivizes voluntary reporting of patient safety information to Patient Safety Organizations (PSOs) by shielding the reported information from discovery in legal proceedings and protecting reporters from adverse employments actions for reporting.
As mainstays of efforts to detect resident safety and quality problems, patient safety event reporting systems are ubiquitous in healthcare organizations. Event reports* rely on those involved—frontline personnel such as nurses, nursing assistants, therapists, pharmacists, and physicians—to provide detailed information about an event and the actions that led up to it. Such reporting is a passive form of surveillance for near misses or unsafe conditions, in contrast to active surveillance methods such as clinical observation or chart review with trigger tools. (AHRQ)
The terms used to describe reportable events in healthcare organizations vary considerably and include "events," "incidents," "variances," "occurrences," "adverse events," "errors," "near misses," "close calls," and many others. In this guidance article, the term "event" is used to denote instances that typically warrant reporting, including near misses.
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 "Adverse") 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 "Adverse").
Several challenges associated with the long-term care environment have been identified as contributing to the prevalence of adverse events in this...