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Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.
Journal Article > Study
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019 Jul 22; [Epub ahead of print].
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015.
Prior research has shown that safety culture is relatively poor among frontline workers in skilled nursing facilities. Trigger tools can help to identify opportunities for patient harm and measure adverse events that occur over time. This toolkit outlines steps to use a trigger tool in skilled nursing facilities, reviews types of events that take place in this setting, and discusses how to analyze trigger tool data to inform improvement work. A past WebM&M commentary discusses challenges to safety in long-term care.
Journal Article > Study
Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. J Patient Saf. 2011;7:92-98.
All North Carolina nursing homes are required to report medication error data. This study reports on a pilot effort to feed back data on error rates to individual nursing homes.
Journal Article > Study
Wagner LM, Capezuti E, Rice JC. J Nurs Scholarsh. 2009;41:184-192.
Residents of long-term care facilities are particularly vulnerable to patient safety problems such as medication errors and falls. Improving safety in nursing homes depends on developing a culture of safety, but this survey of managers and frontline nurses found considerable variation in baseline perceptions of safety culture. Mirroring an issue previously identified in hospitals, nurse managers had a considerably more optimistic view of safety culture than did staff nurses. The authors recommend several interventions, including safety walk rounds, that could address this gap and thereby improve safety culture. The study measured safety climate using a slightly modified version of the AHRQ Hospital Survey on Patient Safety Culture.