The U.S. Department of Health and Human Services Office of Inspector General recently published two toolkits aimed at better preventing patient harm in inpatient settings such as assisted care communities and nursing homes.
The resources can help facility leaders pinpoint and measure adverse events by reviewing medical records. This also can assist in devising policies and best practices to avoid patient harm in the future.
- Medical Record Review Methodology: This toolkit helps leaders define patient harm and classify adverse events by how severe they are — and how preventable, too. It gives tips to help leaders overcome challenges as is the case with complex cases. Harm event criteria includes events when there was a lack of care or during delivery of care, or if a person had side effects from something they took. Criteria didn’t include underlying disease or adverse events that were solely based on pain and not patient harm. It also promotes quality assurance as leaders roll out their plans to prevent patient harm.
- Clinical Guidance for Identifying Harm: Spanning 29 specific injuries and conditions — think sepsis, falls and surgery infections — this guidance helps leaders assess care. Each condition lists if it resulted from harm and if it could have been prevented. It also includes details on the trigger tool that people used to screen for adverse events, and gives leaders suggestions to find and record key details. Trigger tools are broken down by type of facility, such as hospital, rehab facility or long-term care facility.
The documents use a “pick and choose” format that lets providers create or update their medical review procedures. They can customize the way they do things to meet the individual needs of their facilities (they don’t have to use their methodology completely).
But the toolkits are not meant to keep facilities in compliance with laws and other guidance. Instead, they can equip providers put measures in place to prevent patient harm — and report any adverse events if they occur.
