Focused Survey on Medication Safety Systems

Based on findings from an Office of Inspector General repost entitled “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries” CMS is initiating a pilot focused survey that will:

• Identify preventable adverse drug events that have occurred or may occur;
• Determine whether facilities identify residents’ risk factors for adverse drug events and implement individualized interventions to eliminate or mitigate those risk factors; and,
• Determine if the facility has implemented effective systems to prevent adverse drug events as well as recognize and respond to adverse drug events that do occur in order to minimize potential harm for the individual and prevent recurrence of the event.

In the OIG study, it was found that 1 in 3 SNF residents were harmed by an adverse event or temporary harm event within the first 35 days of a SNF stay; and that 37% of these adverse events were related to medication.  The monitoring of residents on anti-coagulant therapy was found to be particularly problematic.

In addition, CMS is releasing the draft Adverse Drug Event Trigger Tool to assist surveyors as they investigate medication related adverse events and to assess whether facilities have implemented effective systems to prevent adverse drug events.   Use of this draft tool is not mandatory but may aid surveyors in assessing compliance around medication issues during standard and complaint surveys.  Nursing home providers may also find it useful as a risk management tool.  The draft trigger tool will be available on the CMS Nursing Home Quality Assurance and Performance Improvement (QAPI) website.

Contact:  Elliott Frost, efrost@leadingageny.org, 518-867-8832