The OIG adverse events study estimated the national incidence of adverse and temporary harm events. It assessed what was preventable and identified contributing factors. It also estimated the costs associated with adverse events to the Medicare program. The study was conducted from 2008-2012, and included 653 Medicare beneficiaries. The beneficiaries were discharged from the hospital to a SNF, and had a SNF stay of 35 days or less. The study included a two-stage medical review.
The study found that an estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. They attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011.