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- Communication Improvement 3
- Education and Training 1
- Error Reporting and Analysis 6
- Human Factors Engineering 2
- Legal and Policy Approaches
- Quality Improvement Strategies 3
- Specialization of Care 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 2
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for "Long-Term Care"
- Long-Term Care
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.
Washington, DC: United States Government Accountability Office; 2005. Report No. GAO-06-117.
This report shares findings from a 5-year review of nursing home quality and safety, which revealed inconsistencies in state surveys that affect the government's ability to adequately address problems in care.
Journal Article > Study
Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.
Briesacher B, Limcangco R, Simoni-Wastila L, Doshi J, Gurwitz J. J Am Geriatr Soc. 2005;53:991-996.
This study explored the effect of a Centers for Medicare and Medicaid Services policy on inappropriate medication use in nursing homes. The authors conclude that the effect of nationally mandated drug reviews is unclear and suggest that more effective safeguards are needed.
Rau J. Kaiser Health News. July 6, 2017.
System failures contribute to recurring problems in health care environments. This news article spotlights how lack of follow-up or action related to inspection reports that have uncovered factors in long-term care facilities that contribute to inadequate care can enable poorly performing nursing homes to remain in operation.
Journal Article > Study
Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.
Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.
Medication errors are common in long-term care facilities, and prior research has shown that many of these errors occur at medication administration. This is particularly a problem at assisted living facilities where non-nursing clinical staff (such as medication aides) are often charged with administering medications. Direct observation of medication administration at two assisted living facilities in this study found that the overall error rate was similar between nurses and non-nurses, but less trained staff from either discipline had markedly higher error rates. As the regulations regarding medication administration in assisted living facilities vary from state to state, the authors advocate for more uniform training standards for all staff authorized to administer medications.
Jt Comm Perspect. August 2010;30:6-7.
This newsletter article discusses the National Patient Safety Goals (NPSG) for 2011 and describes revisions of current NPSGs.
Journal Article > Study
Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to medication errors, as they are often elderly, have multiple chronic illnesses, and take multiple medications. In this study, medication discrepancies (among the hospital discharge summary, SNF referral form, and SNF admission orders) were the rule rather than the exception. Most concerning, many discrepancies involved high-risk medications such as opioid analgesics, anticoagulants, and hypoglycemic agents, which have been linked to serious medication errors in elderly patients. While The Joint Commission has mandated medication reconciliation for long-term care facilities as part of the 2009 National Patient Safety Goals, the authors note that many SNFs do not maintain Joint Commission accreditation, implying that state or national regulations may be needed to improve medication safety across the hospital–SNF transition.
Cases & Commentaries
- Spotlight Case
- Web M&M
Christopher Fee, MD; February-March 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Wolfe W. Minneapolis Star Tribune. February 28, 2007.
This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.
Bailey B, Sevrens Lyons J. The Mercury News. November 27, 2005.
This article reports on several errors that occurred at hospitals in California and discusses the state's regulatory system.
Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.
This article reports on recommendations developed by United States Pharmacopeia (USP) to improve the safety of using medical gas, including revisions to USP monographs.