A lot of attention has been paid to patient safety and avoiding adverse events in the acute care setting. And now that focus is broadening, with a new report that measured incidence rates for adverse events in skilled nursing facilities shedding light on some sobering statistics.
The report, Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries from the U.S. Department of Health & Human Service’s Office of Inspector General (OIG), is based on findings from a study that looked at a sample of 653 Medicare beneficiaries and their experiences in skilled nursing care.
During stays of 35 days or less, 22 percent of the Medicare beneficiaries experienced adverse events—events causing harm that resulted in a prolonged stay or transfer to a hospital, permanent harm, life-sustaining intervention, or death. Of those events, 59 percent were determined to be “clearly or likely preventable.”
So what’s the cause? The report linked the incidents to medication (37 percent), resident care (37 percent), and infections (26 percent). Digging deeper, the events deemed preventable were tied to issues like treatment being provided in a substandard way, residents’ progress not adequately monitored, and errors related to medical judgment, skill, or management.
But what about underlying conditions that might create an environment where these issues are more apt to take place? It’s a connection that’s been explored greatly over the past several years, specifically on the acute care side.
For example, The Center for Health Design’s Anjali Joseph and Ellen Taylor wrote in an article published by sister magazine Healthcare Design: “It’s become increasingly clear that the problem of patient safety doesn’t lie solely in the hands of clinicians or frontline staff. Healthcare systems have many underlying conditions that interact in complex ways and may result in adverse events, such as injuries, errors, and infections. These are known as ‘latent’ conditions that contrast the visible ‘active’ failure. These latent conditions (holes and weaknesses) often go undetected. And those that exist in the physical environment are often incorporated into facilities during planning, design, and construction.”
Some adverse events can more clearly be tied back to the physical environment (falls, for instance, which fell under both events related to medication and resident care in the report), but the effects of the built environment can be even more far-reaching.
This recent OIG report replicates a similar initiative taken in 2010 to study hospital adverse events, and its recommendations today are to follow the path that’s been taken to date in acute care. Specifically, the report says that stakeholders should raise awareness of adverse events in the post-acute setting and work to reduce harm to residents by using methods in place at hospitals, like identifying potential risks and reporting events to patient safety organizations.
To the same end, as a design industry, what can post-acute designers learn from acute care peers? Can parallels between these two corners of the healthcare world be drawn in how design interventions to the built environment can prevent adverse events? To start the conversation, here are some examples of what’s been said regarding safety and hospital design in recent years:
