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Eli's Rehab Report

Inpatient Rehab Hospitals:

Adverse Events: How Does Your Facility Compare?

Medication issues top the list.

The data miners at the HHS Office of Inspector General have looked hard at inpatient rehab hospitals and tallied up the most common adverse events that cause rehab hospital patients to return to acute care hospitals. The OIG’s report, released this past summer, can help you identify potential risks in your own rehab hospitals and compare it to similar facilities in the OIG’s sample.

OIG estimated that slightly less than one-third — 29 percent — of patients were harmed in some way during their stay in inpatient rehab hospitals. That figure is similar to what OIG has previously found for acute care hospitals and skilled nursing facilities.

Out of those instances of harm, reviewers found that nearly half — 46 percent — were “clearly” or “likely” preventable. Why? Physician notes document causes such as substandard treatment, inadequate patient monitoring, or failure to provide needed treatment.

Nearly 25 percent of patients in the sample were transferred to an acute-care hospital for treatment, which leads the OIG to estimate a $92 million annual cost to Medicare.

The biggest culprit was events related to medication (46 percent overall) including:

  • change in mental status due to meds (24 percent),
  • hypoglycemia (9 percent),
  • hypotension (7 percent), and
  • constipation, obstipation, or ileus due to medications (6 percent).

The second biggest culprit were events related to patient care (40 percent) including:

  • bed sores (14 percent),
  • constipation, obstipation, or ileus (9 percent),
  • skin tears other than bed sores (9 percent),
  • and the exacerbation of pre-existing conditions (8 percent).

Rounding out the list were events related to infections (15 percent overall), including: catheter-associated UTIs (5 percent).

It’s worth noting that in OIG’s review of these incidents, three of the sample’s 417 patients died due to one of these adverse events.

With 38 percent of the events “likely” preventable and 8 percent “clearly” preventable, OIG pointed the finger at appropriate treatment given in a substandard way, errors in judgment or skill, inadequate monitoring of a patient, inadequate treatment, and inadequate patient care plan.

“The similarity of results across multiple health care settings suggests that research and interventions to reduce adverse and temporary harm events may be applicable across settings,” OIG summarizes.

OIG offers two solutions. First, rehab hospitals should create and pass out a list of potential problems most likely to occur in their facilities. Second, rehab hospitals should address potential pitfalls in their operating procedures.

“Broadening … patient safety improvement efforts to include rehab hospitals,” OIG concludes, “would ensure that safe care practices promoted in acute-care hospitals and SNFs would extend to other post-acute-care providers.”

Note: Read the OIG report at