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Unintended Health Care Outcomes

A report by the Office of Inspector General (OIG) in 2014 found that 22% of patients in skilled nursing centers experienced an unintended health care outcome, which could be classified into three areas: medication related, care practice related and infections.   Approximately, two-thirds were considered potentially preventable based on review of the medical record by physician and nurse reviewers. Approximately, one third of all unintended health care outcomes resulted in a hospitalization.
Many of the measures outlined in the IMPACT Act (e.g. pressure ulcers, falls, medication reconciliation, rehospitalization) can be classified as measures related to unintended health care outcomes.
Reducing the number of unintended health care outcomes will improve the lives of the patients, residents and families skilled nursing care providers serve.


A number of tools and resources are available to assist member organizations in accomplishing the goals of the Quality Initiative.  Members are encouraged to use the following resources:



Progress will be measured using composite measures of multiple quality measures related to unintended health care outcomes (such as combining rehospitalizations, pressure ulcers, falls, etc).

This measure is under development and should be completed by December 2016 at which time a specific target reduction will be set.  

For more on progress in other areas of the Quality Initiative, click here.

​DISCLAIMER: The AHCA/NCAL quality programs’ contents, including their goals and standards, represent some preferred practices, but do not represent minimum standards or expected norms for skilled nursing and/or assisted living providers. As always, the provider is responsible for making clinical decisions and providing care that is best for each individual person.