In a review of Medicare beneficiaries discharged from rehab hospitals, HHS' Office of the Inspector General found 29 percent of patients examined in the study experienced an adverse event such as bed sores, infection or medication error. Reviewers determined 46 percent of these events were preventable.
For the study, physician reviewers examined records on 417 patients from rehab facilities that were not associated with traditional hospitals. Patients at these facilities are considered to be healthier than patients in hospitals or nursing homes. Reviewers found nearly half of the 158 adverse incidents detected among the Medicare beneficiaries were preventable. Medical errors included deficient treatment, inadequate patient monitoring and failure to provide necessary treatments. Medication errors like bleeding from gastric ulcers due to blood thinners and issues linked to narcotic pain killers made up the bulk of the preventable adverse events.
"This is the latest study over a long time period now that says we still have high rates of harm," David Classen, MD, an infectious disease specialist at the University of Utah School of Medicine in Salt Lake City and developer of the analytical tool used to identify preventable errors in the study, told NPR. "We're fooling ourselves if we say we have made improvement. If the first rule of healthcare is 'Do no harm,' then we're failing."
Approximately one-quarter of the patients that experienced adverse events were sent to acute-care hospitals for treatment. The estimated cost of these events to Medicare was $7.7 million for the month analyzed.
The report recommends CMS and the Agency for Healthcare Research and Quality collaborate to improve patient safety by compiling and disseminating a list of adverse events common to rehab hospitals. According to the report, both agencies have agreed to adhere to this recommendation.
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