This study, reported in The Journal of Geriatric Psychiatry, examines the relationship between dementia and adverse events experienced by older hospital inpatients and looks at whether such events can be prevented.
Reported adverse events (RAEs) are associated with significant injury and even death. Finding ways to decrease the number of adverse events not only reduces the impact on the patients and their families but also saves money.
The study aimed to:
The study involved 710 people aged over 70 years requiring emergency medical admission. Patients were assessed for delirium and dementia. Of the sample group 12.5% had persistent delirium and 42% had dementia.
A total of 8.6 per cent of patients experienced a RAE, 68 per cent of which were patient related ‘slips, trips or falls’ and 22 per cent due to system related errors.
The study found patients with dementia leading to mild/moderate cognitive impairment and functional disability were twice as likely to experience a RAE as those without dementia. Lack of awareness among staff was a concern with a significant number of patients with dementia not recognised by staff as being confused. Comments on incident report cards suggested that staff had not taken account of patients’ dementia when, for example, instructing them not to mobilise without help.
Men were also more likely to have a patient-related RAE for reasons which were unclear, however no association was found between RAEs and mortality.
The report concluded RAEs were associated with risk factors identifiable at admission and that improving staff knowledge and attitudes to those with dementia may enhance the quality of care and reduce adverse events.
Read the article from the The Journal of Geriatric Psychiatry
Read about the Commission’s Reportable Events programme
Download the Serious & Sentinel Events Report for 2010/11