February 20, 2022

The term “adverse event” describes harm to a patient or resident as a result of medical care. An adverse event indicates harm to the patient as a result of medical care, including the failure to provide needed care. Adverse events include medical errors but they may also include more general substandard care that results in patient or resident harm, such as infections caused by the use of contaminated equipment. However, adverse events do
not always involve errors, negligence, or poor quality of care and are not always preventable.

The Centers for Medicare & Medicaid Services (CMS) has compiled information and resources related to adverse events in nursing homes to assist providers to identify, track, and systematically investigate adverse events that have occurred, as well as develop and implement systemic interventions that will help prevent adverse events.

In February 2014, the Office of Inspector General (OIG) released its report Adverse Events in SNFs: National Incidence among Medicare Beneficiaries. It reported that one in three skilled nursing facility (SNF) beneficiaries were harmed by an adverse event or temporary harm event within the first 35 days of their skilled stay. The OIG determined that nearly 60 percent of those events were preventable. The OIG report found that nearly one in three adverse events were related to infections.

Of all the events identified in the OIG report, 37 percent were related to medication. The second most frequent cause of medication related adverse events was excessive bleeding related to anticoagulant use causing harm ranging from hospitalization to death. These findings are further supported by Propublica data reported in a recent Washington Post article which stated, “…from 2011 to 2014, at least 165 nursing home residents were hospitalized or died after errors involving Coumadin or its generic version, warfarin. It is clear that adverse events related to high risk medications continue to be pervasive with devastating effects to nursing home residents.”

In the report on adverse events, the OIG recommended that Centers for Medicare & Medicaid Services (CMS) collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop and promote a listing of potential events that occur in nursing homes to raise awareness of adverse events that harm to nursing home residents. Using the OIG study, CMS and AHRQ worked together to create a list of the most common potentially preventable adverse events.


If you or a loved one suffered injuries (or worse) while a resident of a nursing home in the United States due to an infection acquired in a nursing home, nursing home neglect, nursing home negligence, nursing home abuse, or nursing home fraud, you should promptly contact a local nursing home claim attorney in your state who may investigate your nursing home claim for you and file a nursing home claim on your behalf, if appropriate.

Visit our website to be connected with medical malpractice lawyers (nursing home claim lawyers) in your U.S. state who may assist you with your nursing home claim, or call us toll-free in the United States at 800-295-3959.

Turn to us when you don’t know where to turn.