What’s New in the Patient Safety World

September 2016

Adverse Events in Rehab Facilities



A recent report by the Office of the Inspector General (Levinson 2016) found that 29% of Medicare patients admitted to a post-acute rehabilitation facility (rehab units in acute care hospitals were excluded) experienced either an adverse event or temporary harm event. Almost half (46%) of these were deemed to be likely preventable. About a quarter of the events led to acute care hospitalizations, which were estimated to cost Medicare $92 million annually.


The results were based upon a sample of 417 Medicare patients discharged from such units in March 2012. This event rate is really quite similar to rates the OIG has found for Medicare patients in acute hospitals (27%) and SNF’s (33%). 10% of the patients had an adverse event, which implied harm came to the patient. An additional 18% had events that led to temporary harm. 1.7% of patients had “cascade” events (where multiple related adverse events or temporary harm events occurred in succession). But only 0.7% had events that caused or contributed to their death.


We don’t think the OIG’s report is meant to single out rehab facilities. Rather, it simply demonstrates that all the factors which contribute to adverse events in hospitals are not unique to general hospitals but also occur in almost all healthcare settings.






Levinson DR (Office of the Inspector General. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. July 2016








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