OIG Issues Report on Adverse Events in Rehabilitation Hospitals.

Date posted: August 1, 2016

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a study estimating the national incidence rate, preventability, and costs associated with adverse events.  The OIG study aims to educate providers on improving patient care safety in rehabilitation (rehab) hospitals.  Adverse events involve harm resulting from medical care that is not caused by an underlying condition.  Rehab hospitals include providers specializing in post-acute, intensive treatment for patients recovering from illness, injury, or surgery.  The OIG reviewed a sample of medical records for Medicare beneficiaries discharged from rehab hospitals in March 2012.

The report includes the following findings:

  • Roughly 29 percent of Medicare beneficiaries experienced an adverse event while at a rehab hospital, similar to other hospitals and skilled nursing facilities;
  • Adverse events caused a variety of outcomes, including temporary and permanent harm, transfers or prolonged stays, necessary life-sustaining intervention, and death;
  • Approximately 46 percent of adverse events were preventable and resulted from below average treatments, insufficient monitoring, and general failure to treat;
  • Medication and patient care were the most frequent adverse events, while infections were the least frequent; and
  • Adverse events cost Medicare roughly $92 million in 2012.

The OIG recommended that CMS:

  1. Raise awareness of the patient safety issues causing adverse events to reduce patient harm;
  2. Collaborate with the Agency for Healthcare Research and Quality to compile and distribute a list of commonly occurring adverse events in rehab hospitals; and
  3. Create quality guidance concerning adverse events for rehab hospitals.

The OIG report is available at:


Department of Health and Human Services Office of Inspector General.  “Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.”  OEI-06-14-00110.  19 Jul. 2016.

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