OASIS Alert

Nobody's perfect but with the right preparation you can be pretty close.

Don't learn about what outcomes mean through survey deficiencies, advised Charlotte Hughes with Gentiva Health Services. The Centers for Medicare & Medicaid Services "considers Tier 1 adverse events to be a major issue," she remarked at the National Association for Home Care & Hospice's annual policy conference in Washington April 9.

Rather than wait to be told what to do, you can choose your own response to adverse events through effective risk management activities. This heads off survey problems while improving patient care, she said. Hughes suggested agencies:

1. Develop a review process to identify potential problems.

2. Sort out potential and true adverse events from clerical errors. Find out if the event in question really happened.

3. Determine how to improve accuracy, if the problem is a data entry or other clerical error.

4. Ask if you could have prevented the event from occurring. Could you have taken reasonable action?

5. See if the record supports reasonable prevention efforts.

6. Find out if you evaluated risk, taught the patient and family and documented these actions.

7. Document what actions you took to prevent the problem from happening again, such as patient teaching, staff in-service, patient assessment or conferencing with the physician.

8. Determine how you can broaden the scope of the risk management activities to prevent similar problems with other at-risk patients.

9. Get in front of adverse events don't wait for them to happen. Beginning with the start of care conference, address risk areas (multiple medications, poor balance). Then incorporate systems in the plan of care to prevent adverse events.

10. Examine discharge summaries. Poorly written summaries put you at risk for charges of premature discharge.

The summary should record what the clinician taught the patient, the return demonstrations, what the family understood, what symptoms the clinician told the patient and family to report to the physician and that they were told how to contact the agency if needed.