According to a recent HHS Office of Inspector General (OIG) report, about 29% of Medicare beneficiaries experienced adverse or temporary harm events during their rehabilitation hospital stay, based on sample of 417 beneficiaries in March 2012. This rate is similar to the incidence of adverse events in acute-care hospitals and skilled nursing facilities. The OIG estimates that 46% of the rehab hospital adverse or temporary harm events were clearly or likely preventable, attributable to such factors as substandard treatment, inadequate patient monitoring, and failure to provide needed treatment. One quarter of impacted patients were transferred to an acute-care hospital for treatment.

To raise awareness of patient safety issues in rehab hospitals and reduce patient harm, the OIG recommends that CMS: (1) collaborate with the Agency for Healthcare Research and Quality (AHRQ) to create and disseminate a list of potential adverse events that occur in rehab hospitals and (2) include information about potential adverse events in quality guidance to rehab hospitals. CMS and AHRQ concurred with the OIG’s recommendations. CMS also noted that it plans to look into using the Quality Improvement Organization Program to assist with quality improvement efforts in rehab hospitals.