OIG's Adverse Events Toolkits: Preventing Patient Harm

Adverse Events toolkits by the Department of Health and Human Services Office of Inspector General are designed to aid health care professionals and decision-makers in preventing harm to patients in hospitals, nursing homes, and other inpatient settings. Lee Adler, DO, infectious disease specialist, AdventHealth System; and Amy Ashcraft, MPA, a deputy regional inspector general with the Department of Health and Human Services Office of Inspector General (OIG) spoke with Infection Control Today^® (ICT^®)about the Adverse Events Toolkits recently published by the OIG.

Ashcraft provides insight into the inspiration behind the creation of the toolkits. “As an oversight agency for the Department of Health and Human Services, we have responsibilities for both Medicare and Medicaid programs, and ensuring that patients are receiving safe care and effective care is a huge priority for the OIG. We're invested in this topic area; we've been doing work on patient safety for over 15 years and have produced almost 20 reports on the topic. And when we talk about adverse events, I want to clarify…that we are talking about all causes of harm, we don't focus on a specific list. And we include both preventable and nonpreventable events that may be important to some of your viewers.”

Washington, USA, US Treasury Department and Inspector General Office.

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Ashcraft continued, “As we've been doing this work, we found that patient harm is commonplace in every inpatient setting. And the rates range from 13 to 46%, depending on the setting that you look at. I wanted to tell you about our most recent report, which we released in May 2022. It was the seventh medical record review looking at a national incidence rate of patient harm. And we found that about a quarter (1 in 4) of Medicare patients experience harm during hospital stays, and almost half of those were preventable.”

Ashcraft pointed out to ICT viewers that infections “were the smallest category of types of events that we've looked at and comprise about 11% of the adverse events. The most common ones were respiratory infections, surgical site infections, and thrush. And in terms of why it's important, it's imperative that hospitals and other health care settings monitor their rates of adverse events and patient harm. And we released these toolkits because we wanted to share what we've learned conducting this work so that others can build upon it.”

The toolkits should not be considered perpetual. “It's important for those who read the document to understand that [the toolkits were created and written at a certain] point in time because evidence and practices change and what was not preventable,” Adler said. “In the past, for instance, central line infections [were considered nonpreventable but] are now considered preventable. Also, sepsis says another indication of where they were using lots of fluid years ago in as part of the best practices, and now we are very careful and how much fluid we give a patient not to overload them. If anybody's going to use this toolkit, they need to look at the latest guidance, whether it's the CDC guides, NHSN, or the Infectious Disease Society. And it's important that this is a document and appointed time that each time it's used [the information] needs to be updated.”

The toolkits were created with the help of many experts from many different fields of study to get the best practices. Ashcraft explains, “These [toolkits] represent numerous hours of research and case-specific conversations. It's a living document. And for each study, we would revisit the basic guidance document and add to it considering anything that has changed and the recommended practices over the intervening years or that are specific to a set setting that we're looking at. And get input from our panel of physicians; we had 6 high-level physicians with a range of specializations, including infectious disease, cardiology, surgery, neurology, and orthopedics. I could go on, but we tried to cover a wide range of specializations. And whenever we didn't have the specialization that we needed, Dr. Adler would go out and find someone that would help us to make sure we got the most accurate information for people working in that field. And then, in addition to that, as we were manually reviewing cases, we would come together weekly and talk about those cases.”

Ashcraft emphasized that these toolkits are only tools. “We're not anticipating that people are going to use this as a cookie-cutter approach. And that's why we made it what we termed a “pick-and-choose” resource. You can take the parts that are useful to your organization and apply them and modify them to what is most appropriate.”

(These quotes have been lightly edited for clarity. To hear the entire discussion, click the video above.)