Steps Your Hospital Can Take to Improve Patient Outcomes

One in four Medicare patients experienced harm during their hospital stays over the course of a month in 2018, according to a new report from the U.S. Department of Health and Human Services Office of Inspector General. 

The report, the follow up to a 2010 study, sought to update the national incidence rate of patient harm events, calculate a new rate of preventable events and update the cost of patient harm to the Medicare program.

Below we review the report’s methodology, findings, the OIG’s recommendations, as well as steps hospitals can take to improve patient outcomes and safety in their facilities.

The study’s methodology

For the study, the OIG reviewed medical records of a random sample of 770 Medicare patients that were discharged from acute-care hospitals during October 2018. 

The OIG conducted a two-stage medical record review. In the first stage, nurses screened records for possible patient harm events using a “trigger tool” method – a trigger is a clinical clue (such as a documentation of a fall) that may indicate harm. Nurses also reviewed present-on-admission indicators in Medicare claims data to identify harm that developed after the patient was admitted. In cases where patients were readmitted within 30 days of discharge, the nurse reviewers automatically referred the records to the next stage of review, regardless of whether harm was identified. 

In the second stage, physicians reviewed records flagged by nurses as containing possible harm events. They identified harm events and assessed the severity of the events, whether they were preventable and the factors that contributed to the events. 

Medication harm most prevalent

The study covered both adverse events and temporary harm events in their review of patient harm. For the purposes of this study the OIG defined adverse events as events leading to longer hospital stays, permanent harm, life-saving intervention or death. Temporary harm events were defined as events requiring intervention but did not result in long-lasting harm, prolonged hospital stays or require life-sustaining measures. Of the 25 percent of patients in the study that experienced harm, the division between adverse events and temporary harm events was relatively even.

Of all harm events medication-related harm was most common, making up 43 percent of incidents. These incidents included patients experiencing delirium or other changes in mental status, hypotension, acute kidney injury, excessive bleeding and hypoglycemia, according to the report. 

Harm stemming from patient care made up 23 percent of the reported events. This category includes skin tears, patient falls and pressure injuries, a common preventable injury that is especially costly for healthcare providers. 

Other types of harm stemmed from procedures and surgeries (22 percent), including hypotension, excessive bleeding and embolisms, and infections (11 percent), including sepsis and C. diff, respiratory and surgical site infections. 

Preventable harm linked to care quality

56 percent of harm events were deemed not preventable and occurred despite providers following proper procedures. There were several reasons why these events were determined as not preventable, including events where patients were found to be highly susceptible due to their health status. The physician-reviewers determined that 43 percent of harm events were preventable. 

One finding underscores the importance of patient care in preventing harm events. The physician-reviewers determined that 52 percent of the events involving patient care-related harm were preventable, as compared to 42 percent of events involving medication and 25 percent of the events involving procedures or surgeries. 

The OIG concluded that 23 percent of Medicare patients who experienced harm events required treatment, leading to increased Medicare costs estimated to be in the hundreds of millions of dollars.

Additional significant findings in the report related to Centers for Medicare and Medicaid Services policies that incentivize hospitals to prevent harm by reducing payments for certain hospital-acquired conditions, also known as HACs. 

OIG found that because the policies use narrowly scoped lists and employ specific criteria for counting harm events, they have limited effectiveness in promoting patient safety. 

The OIG said that current CMS HAC lists did not cover most of the harm events that patients in the study experienced — only five percent were on the HAC Reduction Program list and only two percent were on CMS’s Deficit Reduction Act HAC list. 

Report Recommendations

The OIG concluded that addressing patient harm and promoting patient safety takes on an added urgency as hospitals continue to respond to the ongoing effects of the COVID-19 pandemic on hospital operations. 

“Despite substantial action by HHS agencies and success in reducing certain types of events, patient harm remains pervasive, is often preventable, and continues to cost the Medicare program and patients,” the report said. 

The OIG called on HHS leaders and agencies to work urgently to address “these persistent harm rates and promote safety in hospitals.” 

To that end, the OIG issued a series of recommendations to both CMS and HHS’ research arm, the Agency for Healthcare Research and Quality, or AHRQ. 

The OIG made three recommendations to CMS: 

  • Update and broaden HAC lists to capture common, preventable and high-cost harm events;
  • Explore expanding use of patient safety metrics in pilots; and 
  • Develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm

The recommendations to AHRQ included: 

  • Coordinating agency efforts to update agency-specific Quality Strategic Plans;
  • Optimizing use of the Quality and Safety Review System;
  • Developing an effective model to disseminate information on national clinical practice guidelines or best practices to improve patient safety; and
  • Continuing efforts to identify and develop new strategies to prevent common patient harm events in hospitals

4 Steps to Improve Outcomes

When patients are harmed during their hospital stays, not only is it a concern of the U.S. government and taxpayers, as in the case of Medicare patients: these harm events can become increasingly costly for hospitals to litigate. 

Here are four ways your hospital can improve patient outcomes and safety. 

1. Engage an outside party to review hospital data to identify areas of improvement. While legal-nurse consulting experts are regularly engaged in litigation, they can also play a proactive role in reviewing hospital data, identifying areas of concern and advising hospitals on changes they can make to prevent costly litigation down the road. Hiring a neutral third party can be especially valuable for hospitals in terms of receiving a more objective picture of what’s happening in their facilities. 

2. Leverage data to improve safety policies and procedures. Legal-nurse consulting experts’ unique medical-legal expertise enables them to conduct a deep-dive into hospital records, identify facility-specific trends and areas of weakness, and then use those insights to develop practical recommendations for hospitals to implement to avoid future legal exposure. Legal-nurse consulting experts provide recommendations for immediate next steps as well as policies and procedures that can help improve patient outcomes and safety. 

3. Invest in training staff on safety. As the saying goes, an ounce of prevention is worth a pound of cure. Once hospitals have firm next steps and new policies and procedures, they need to make sure their employees are well-trained in them. Investing in training workers up front pays dividends in terms of creating a broader culture of patient safety within an organization. Ensuring clinical staff are well trained on best safety practices is an investment in minimizing patient harm and exposure to liability for preventable incidents.

4. Engage legal-nurse consulting experts to thoroughly review litigation matters. Once litigation has occurred, legal-nurse consulting experts can provide more than just assistance on a particular matter. Yes, they can review medical records and give opinions on hospital liability and whether the standard of care was met, but they can also use the information they’ve captured through litigation to provide feedback to hospitals and recommend improvements. For hospitals already paying for legal-nurse consulting experts, this is a value-add beyond just analyzing a particular case – it helps hospitals get more bang for their litigation buck. 


The OIG report highlights a troubling truth: a decade after the OIG’s first report on patient harm events, the needle has not moved significantly in terms of improving outcomes for Medicare patients. 

While the report offers some insights into some reasons as to why that may be the case – the prevalence of comorbidities in the Medicare population is rising, as is the number of patients being treated for clinically-complex conditions and diagnoses – the report underscores the need for hospitals to do more to improve patient outcomes and safety. 

For hospitals looking to improve patient care, legal-nurse consulting experts provide a cost-effective means to determine areas of improvement and act on them. Med Law Advisory Partners works closely with hospitals to help them improve outcomes and patient safety.

Our team is equipped to capture vital information from extensive data collection in litigation, discern trends in care, identify system defects, and bring recommendations to clinical teams to improve patient outcomes and safety. We partner with health systems to bring unique expertise that is highly cost-effective and cost-saving in an era where both quality of care and financial stewardship are critical priorities. 

Contact us today for more information about how our team can assist yours in improving patient outcomes.

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