Learning from Adverse Events & Incidents

Learning from Adverse Events & Incidents

Studies show that nearly one in three skilled nursing facility residents experience an adverse event during their stay, with approximately 60% of these events being potentially preventable. Adverse events in skilled nursing facilities may include falls, medication errors, the development of pressure areas, elopements, and/or healthcare associated infections. How effectively are you using adverse event data as a performance improvement opportunity?

CMS defines an adverse event as “an untoward, and usually unanticipated event that causes death, serious injury, harm or the risk thereof”. CMS uses this definition to identify and address patient safety concerns in healthcare settings. Studies show that nearly one in three skilled nursing facility residents experience an adverse event during their stay, with approximately 60% of these events being potentially preventable. Adverse events in skilled nursing facilities may include falls, medication errors, the development of pressure areas, elopements and/or healthcare associated infections. The occurrence of adverse events offers significant opportunities for learning and systems improvement –beginning with identifying and analyzing errors and gaps in current processes in order to prevent recurrence and promote resident safety. Consider these elements of your QAPI process when addressing adverse events:

Reporting and Documenting incidents:

• • • A key piece in the learning process is the use of a system for documenting and reporting adverse events including near misses and incidents that can lead to harm. This data can assist with tracking adverse events and identify trends to support improvement. Comprehensive documentation related to adverse events will also help to identify where system vulnerabilities exist.

Root Cause Analysis

• • • Once the documentation is complete, the next step in the process is to conduct a root cause analysis. The root cause analysis moves beyond the individual issue of what happened, to look at why the event occurred and to identify systemic issues that may have contributed to an undesirable outcome. By conducting a deeper dive into factors, such as environmental hazards, gaps in policies and procedures, inappropriate protocols, breakdowns in communication and other system failures, action can be taken toward the development and implementation of targeted interventions aimed at the root cause rather than merely treating the symptom.

Implementing Change

• • • Corrective actions designed to effect change at a systems level are most effective in preventing adverse events and incidents. This QAPI driven approach will lead to sustainable change through interventions that include process improvements, staff education and training, and/or enhancements in technology.

Monitoring and Evaluation

• • • Continuously monitoring the effectiveness of the changes that have been implemented and evaluating their impact is key to sustained improvement.

Establish a Culture of Learning

• • • Encourage an educational approach that facilitates open communication and reporting of adverse incidents and near misses without fear of blame—again, by focusing on gaps in systems and not individual causes whenever possible.

Celebrate Successes

• • • When improvements are made and identified, take time to share the success with the IDT, residents, and families. For example, if there is a sustained period of time with no falls with major injury, letting the team acknowledge and celebrate this success can promote greater success.

Next Steps:

Did you miss this week’s session of Driving QMs through Clinical Excellence? Register to join us for the upcoming class on June 11th.

Contact Proactive for a review of your QAPI program and for assistance in developing your Q3-2025 QAPI plan.

Schedule a deep dive Quality Measure analysis to uncover missed opportunities that may be holding you back from achieving 5 star QMs

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