PATIENT safety has become a major public health

Journal of Gerontology: MEDICAL SCIENCES 2003, Vol. 58A, No. 9, 813–819 In the Public Domain Review Article Patient Safety in Geriatrics: A Call fo...
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Journal of Gerontology: MEDICAL SCIENCES 2003, Vol. 58A, No. 9, 813–819

In the Public Domain

Review Article

Patient Safety in Geriatrics: A Call for Action Dionyssios Tsilimingras,1 Amy K. Rosen,1,2 and Dan R. Berlowitz1,2 1

Center for Health Quality, Outcomes, and Economic Research, Bedford Veterans Affairs Medical Center, Massachusetts. 2 Boston University School of Public Health, Department of Health Services, Massachusetts.

Patient safety has become a major public health concern following the publication of the landmark report, To Err Is Human, by the Institute of Medicine in 1999. This report, along with a subsequent report, Crossing the Quality Chasm, recommended the design of a safer health care system by integrating well-established safety methods to avert medical errors. However, neither patient safety report specifically addressed the implications of safety for elderly patients. This article examines those implications by describing the association between aging and medical errors, identifying geriatric syndromes as medical errors, and focusing on six recommendations that will improve the safety of geriatric care. These six recommendations include the detection and reporting of geriatric syndromes, identifying system failures when geriatric syndromes occur, establishing dedicated geriatric units, improving the continuity of care, reducing adverse drug events, and improving geriatric training programs.


ATIENT safety has become a major public health concern following the recent publication of the landmark report by the Institute of Medicine (IOM) (1). The IOM report, To Err Is Human, estimated that 44,000 to 98,000 deaths with 1 million injuries occur from medical errors each year in American hospitals alone, while excluding nursing homes and other health care facilities, and with a total annual national cost estimated between $17 and $29 billion (1). The IOM set forth a national agenda focusing on initiatives at the state and local levels, and within health care organizations and professional groups, to reduce errors and improve the quality of care in America (1). The release of this report has stimulated an array of national initiatives from governmental, business, and medical leaders to produce recommendations for the reduction of errors within our health care institutions (1). In a subsequent report entitled Crossing the Quality Chasm, the IOM highlighted quality-related issues by providing strategies to redesign the current health care system, including the use of existing medical knowledge and information technology by clinicians to properly care for their patients (2). Neither patient safety report specifically addresses the implications of safety for elderly patients. Yet, elderly patients have a unique vulnerability for medical errors that needs to be addressed. Recommendations that include the implementation of systemic approaches to improve safety in geriatric settings are particularly critical. Therefore, it is our contention that a detailed understanding of the patient safety movement is crucial if geriatricians are to continue improving care for elderly people. With regard to the close relationship between patient safety and geriatrics, we believe that it is imperative for geriatricians to acquire the tools necessary to expand their knowledge on patient safety and initiate efforts to implement safe practices when providing care for elderly people. Thus, this paper focuses on the implications of safety for elderly patients and the geriatric practice. We accomplish this by

examining three issues. First, we describe the association between aging and medical errors. Second, we explain why many geriatric syndromes should be considered as medical errors. Third, we expand on the IOM reports and the AHRQ (Agency for Healthcare Research and Quality) evidencebased report on safety practices (3), by presenting specific recommendations for the improvement of geriatric care. AGING AND MEDICAL ERRORS Elderly people appear to be a group particularly at risk for medical errors. A medical error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors do not always result in medical injury. Errors that result in medical injury to the patient are sometimes called preventable adverse events. An adverse event is defined as an injury caused by medical management rather than by the underlying disease or condition of the patient (1). Adverse events are not always preventable. An unavoidable adverse event can occur from an unknown drug reaction in a patient who has received the appropriate administration of a particular drug for the first time. If a drug reaction occurred in a patient who knowingly had a previous allergic reaction to that particular drug, the adverse event would be due to negligence (4). Negligence is defined as whether the care provided failed to meet the standard of care reasonably expected of an average physician qualified to take care of the patient in question (5). An adverse event can also result from an error of omission, when a necessary procedure or intervention failed to be performed leading to morbidity or mortality to the patient involved (6). The occurrence of adverse events associated with elderly people has been well documented in the literature for decades by Justiniani and colleagues, Steel and colleagues, and Jahnigen and colleagues (6–8). However, these adverse event studies and others, until the Harvard Medical Practice Study (HMPS), have been restricted to nonrandom samples 813



of particular institutions with a small number of records (6– 10). The HMPS was the first study to randomly select a large number of records involving many institutions and to develop more current and more reliable estimates for the incidence of adverse events and negligence involving hospitalized patients (4). The HMPS examined a random sample of over 30,000 patients hospitalized in 1984 at 51 hospitals in New York State. Adverse events related to treatment occurred in 3.7% of patients with 27.6% of the adverse events resulting from negligence (4). Over 70% of adverse events contributed to disability lasting less than 6 months, with 2.6% resulting in permanent disability and 13.6% leading to death (4). The HMPS disclosed that patients aged 65 years and older accounted for 27% of the hospitalized population but 43% of all adverse events (5). The rate of adverse events increased significantly with age, placing individuals aged 65 years and older at a two-fold risk for developing adverse events when compared with individuals between the ages of 16 and 44 years (4). A subsequent medical practice study examined a random sample of 15,000 hospitalized patients in Utah and Colorado in 1992, and found similar results to those of the HMPS in respect to incidence and types of adverse events (11). In a more recent study of patient safety indicators conducted by AHRQ, the highest rates of patient safety events related to errors were found among individuals between the ages of 65 to 74 years (12). A quality improvement study among high-risk elderly patients at a teaching hospital found more than half of all adverse event complications to be potentially preventable and care below standards was associated with more complications (13). Errors of omission also occur frequently in elderly people. For example, underutilization of medications in elderly patients with coronary artery disease has been described in a variety of settings (14,15). While several studies have identified the types of adverse events that are predominant in elderly persons (e.g., adverse drug events, procedure-related events, and falls), the reasons for the elder’s predisposition remain unclear (5,7,8,16–20). There are, however, two possible mechanisms that should be considered. First, older patients have more diseases that contribute to longer hospital lengths of stay and an increased exposure to hospital-related insults from medications and procedures (5,16,21,22). Second, elderly people are often frail. Frailty can be considered as a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes (23). Consequently, the stress of many common medical procedures and treatments will more likely result in an adverse outcome. Increased predilection to medical errors and associated adverse outcomes may be one mechanism by which frailty predicts mortality (24). Further research is needed, however, to identify the role of each of the mechanisms in elderly people that are predisposed to adverse events. GERIATRIC SYNDROMES AS MEDICAL ERRORS Central to geriatrics is the management of a variety of medical conditions commonly referred to as ‘‘geriatric syndromes,’’ which include falls, delirium, pressure ulcers,

and underfeeding. These geriatric syndromes tend to develop when the compensatory ability of elderly people is compromised by the accumulated effect of impairments in multiple domains (25). It is our contention that these geriatric syndromes often should be viewed as medical errors for the following three reasons. First, these geriatric syndromes are associated with increased mortality (Table 1). For example, the incidence of unintentional injury, which most often results from a fall, ranks among the top 6 causes of death in those over the age of 65 years (26). The development of delirium among hospitalized elderly patients is associated with mortality rates of 25% to 33% (27). The mortality rate for residents with pressure ulcers in Veterans Affairs longterm care facilities was 26% over a 6-month follow-up period (28). Underfeeding is also associated with poor clinical outcomes and is an indicator of risk for increased mortality (24,29,30). The mortality rate associated with underfeeding in anergic residents from a Medicare-approved nursing home was 48% during a 6-month period (31). Second, the literature has shown that these geriatric syndromes in many cases can be prevented from occurring (Table 1). For example, a research agenda on the prevention of falls concluded that falls are potentially preventable if the optimal prevention strategy is identified (32). An optimal prevention strategy for underfeeding could include a clinical guide that may assist in the prevention of malnutrition in long-term care (29) or the administration of an agent such as megestrol acetate to prevent further unintended weight loss and improve appetite, caloric intake, pleasure from eating, and weight gain in nursing home patients (33). Other studies have suggested that the incidence of geriatric syndromes can be reduced with the implementation of systemic policies at both the national and local levels (25,27). Geriatric syndromes can also be reduced or prevented with strategies such as staff education and multicomponent interventions (22). Third, the prevention of geriatric syndromes often requires a systems approach to care. A systems approach implements a set of interdependent elements (including both human and nonhuman) interacting to achieve a common aim (1). Numerous studies in geriatric care have used a systems approach and have documented that improved outcomes are achieved through changes in the delivery of care. A prime example in geriatric care has been the implementation of Acute Care for the Elderly Units (ACE Units) (34). ACE Units have promoted the independent functioning of geriatric patients by preventing the physical environment and the processes of care from contributing to functional decline (34). Thus, they may mitigate the effects of the many known predictors of functional decline including age, comorbidity, baseline functional status, and cognitive impairment (35). Key elements of ACE Units have included a prepared environment, patient-centered care emphasizing independence, discharge-planning emphasizing the home environment upon discharge, and intensive review of care to minimize the adverse effects of procedures and medications (36). The prepared environment in ACE Units has included structural features such as carpeting, handrails, uncluttered hallways, large clocks and calendars, elevated toilet seats, and door levers for the independent functioning of elderly people (36). Without such specific systemic changes, the individual



Table 1. Adverse Outcome and Systemic Intervention Results for Geriatric Syndromes Considered Medical Errors Adverse Outcomes Delirium

MR 25%–33% (27)

Preventability 40% reduction (21)

8% and 14% (37)* BE, 0.82 (RR) (48){

81% reduction (72) 19% reduction (73) 19% reduction (74) 14% reduction (75) Falls

Top 6 causes of death (26) 

31% reduction (38)

25% reduction (76) 19.1% reduction (77)

Improvement (39)à Pressure ulcers

MR 26% (28)

63% reduction (41) BE, 0.82 (RR) (48){ 37% reduction (78)§


MR 48% (31)

Increased intake (40)jj

Systemic Intervention Multicomponent intervention consisted of standardized protocols for the management of 6 risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration (21) Hospital elder life program screened on admission for 6 risk factors (cognitive impairment, sleep deprivation, immobility, dehydration, & vision or hearing impairment) (37) Yale geriatric care program included surveillance and identification of frail older patients, unit-based geriatric educational programs for all nurses, special education and support for the geriatric resource nurses, and twice-weekly rounds of the geriatric care team (48) Postoperative reorientation by nursing personnel in the intensive care unit, orienting the patient to time, place, and physical status (72) Preoperative nurse investigators discussed with patients the possibility of memory loss, impaired concentration, and hallucinations after surgery (73) Preoperative psychiatric assessment and postoperative nursing support and reorientation (74) Pre- and postoperative examinations and treatment by geriatricians and anesthesiologists (75) Multifactorial program that included medication review, education, training in gait and transfer skills, changes in environmental hazards, strengthening exercises, and behavioral modifications (38) Nurse assessment visit and follow-up interventions targeting risk factors for disability and falls (76) Multidisciplinary program consisted of individual patient assessment that targeted environmental and personal safety hazards (e.g., floor surfaces, lighting, and bathroom equipment), psychotropic drug use, wheelchair assessments (e.g., missing foot and leg rests), and staff education on the use of safer transferring techniques (77) Multifactor fall risk reduction program included fall risk education, home-based exercise programming, nutrition counseling, and environmental hazards (39) Intensive educational program for physicians and nurses regarding the pathogenesis, staging, prevention, and treatment of pressure ulcers (41) Yale geriatric care program (see above for description) (48) Multidimensional interventions included best practices and research-based protocols to prevent and treat pressure ulcers (78) The intervention offered a 2-day, or 6 meal, trail of one-on-one feeding assistance to nursing home residents (40)

Notes: Numbers in parentheses indicate the reference number. MR ¼ mortality rate. *Only 8% of admissions involved patients who declined by 2 or more points on MMSE (Mini-Mental State Examination) score and 14% who declined by 2 or more points on ADL (activities of daily living) score between admission and discharge. { Stratified analyses resulted in a beneficial effect (BE) with a relative risk (RR) of 0.82 (95% CI) in patients with 1 of 4 geriatric target conditions at baseline (e.g., delirium, functional impairment, incontinence, and pressure sores).   Over the age of 65. à Statistically significant improvement in balance, biceps endurance, lower extremity power, reduction of environmental hazards, falls efficacy, and nutritious food behavior. § A 37% reduction in the predicted prevalence rate was achieved within a 2-year period. jj The intervention increased oral food and fluid intake during mealtime in 50% of the participating nursing home residents.

clinician would be able to do very little to improve care for elderly people. Additional systemic initiatives have included the implementation of hospital elder life programs (37) and multicomponent interventions to reduce delirium (21). These systemic approaches have targeted specific risk factors such as cognitive impairment to reduce the occurrence of delirium (21,37). A multifactorial intervention program that included medication review, education, training in gait and transfer skills, changes in environmental hazards, strengthening exercises, and behavioral modifications reduced the occurrence of falls in the home setting by 31% (38). A multifactor fall risk reduction program that included fall risk education, home-based exercise programming, nutrition counseling, and environmental hazards education improved outcomes in a group of community-dwelling older adults

(39). An intervention for undernutrition that offered a 2-day, or 6-meal, trial of one-on-one feeding assistance to nursing home residents significantly increased oral food and fluid intake during mealtime in 50% of the participating residents (40). Other initiatives have demonstrated that staff educational programs can reduce pressure ulcers (41). A staff educational program involving a team of physicians and nurses reduced the development of pressure ulcers by 63% by emphasizing early assessment and instituting simple preventive techniques (41) (Table 1). These studies emphasize that initiatives from individual clinicians will rarely be sufficient to prevent geriatric syndromes from occurring. Orders to turn a patient every 2 hours to prevent pressure ulcers, or to promote sleep in a quiet environment to prevent delirium, will not be effective unless the appropriate systems are in place. Thus, a successful re-



duction in geriatric syndromes necessitates the construction of an environment that would allow the implementation of best practices to create safer and healthier care settings for elderly persons. RECOMMENDATIONS FOR THE IMPROVEMENT GERIATRIC CARE Many recommendations for effective safety practices have been proposed by the IOM and the AHRQ (1–3). These recommendations focus on designing a safer health care system by integrating well-established safety methods to avert medical errors. We believe that these recommendations can and should be applied to geriatrics. Furthermore, we have identified and expanded on six specific recommendations that we believe will improve the safety of geriatric care. These six recommendations include the detection and reporting of geriatric syndromes, identifying system failures when geriatric syndromes occur, establishing dedicated geriatric units, improving the continuity of care, reducing adverse drug events, and improving geriatric training programs. OF

Detecting and Reporting Geriatric Syndromes Detection and reporting of medical errors is a vital safety practice that should be adopted in geriatrics. Geriatricians should detect and report preexisting and new-onset geriatric syndromes (such as pressure ulcers, delirium, falls, and underfeeding) that will enable them to instigate an immediate treatment plan. This practice would later assist geriatricians to investigate the underlying systemic failures that result in new-onset geriatric syndromes. If geriatric syndromes are not detected or reported, the identification of systemic failures and the initiation of immediate medical attention will not occur. The failure to identify systemic failures and to initiate immediate medical attention will result in avoidable harm to elderly people. However, the fear of discipline or retribution from organizations providing employment and privileges prevents clinicians from acknowledging and managing errors in which they have been involved (42). Conclusions have been reached that most errors result from a complex interrelationship that involves multiple factors (43,44). Rarely are errors due to negligence or misconduct of individual clinicians (43). The evidence overwhelmingly suggests that error in medicine is due primarily to systemic and organizational failures (43–45). Therefore, efforts should avoid punishing individual clinicians and focus on designing a system that would encourage detection and reporting of errors. Such a system would allow clinicians to learn from the mistakes of others and prevent them from repeating similar mistakes. Identifying System Failures When Geriatric Syndromes Occur Once geriatricians have detected and reported geriatric syndromes, it is important to identify the underlying system failures that result in geriatric syndromes. In a recent article, a patient safety committee captured process and decisionmaking failures after examining errors in a sequential chain of clinical events beginning with the initial care decision to the adverse event leading to an error (46). An example of

this approach for geriatricians is to identify new-onset geriatric syndromes (such as pressure ulcers, delirium, falls, and underfeeding) and retrospectively outline the sequential chain of clinical events leading to their occurrence. The sequential chain of clinical events could include human factors such as the reasons that physicians failed to recognize the occurrence of geriatric syndromes and why physician orders were not executed in a timely manner by nonphysician staff to prevent geriatric syndromes. Additional factors could include technical factors involving a computer system and organizational factors such as a payment system that required preauthorization for the care of patients (46). By outlining the sequence of clinical events that led to the development of geriatric syndromes, geriatricians would be able to identify systemic failures and develop solutions to reverse their outcome. Geriatricians should apply this approach and formulate additional approaches to identify systemic failures.

Establishing Dedicated Geriatric Units Studies have convincingly demonstrated that outcomes of elderly patients are better in environments that have been tailored to their unique needs (21,34,36,37,47,48). These environments have succeeded in reducing functional decline and geriatric syndromes by imposing specific changes to the elements of hospitalization and ensuring that specific practices actually occur when care is provided for elderly persons. These environments are unique because they have directed specific interventions not only to patients whose functional status has already declined while in the hospital, but also to prevent patients from functional decline throughout their hospitalization. Gillick takes this concept even further by suggesting the creation of geriatric hospitals for treatment of most medical and surgical problems and for provision of rehabilitative or skilled nursing care (49). Thus, it is imperative for geriatricians to encourage efforts to establish dedicated units for the care of elderly people. Improving the Continuity of Care Several studies have emphasized that improvements in patient care will occur with improvements in the continuity of care among health care providers (45,50–52). Discontinuities in care often take place when medical information such as a patient’s drug allergy or prior therapeutic drug failure is not transferred from outpatient to inpatient pharmacies when a patient is admitted to a hospital (53). Improving information transfer between outpatient and inpatient pharmacies is a vital safety practice that will reduce adverse events. Discontinuities in care can often result from unstructured cross-coverage sign-outs between physicians. One study found that preventable adverse events were six times as likely to occur during unstructured cross-coverage sign-outs (54). A different study concluded that there were significantly fewer adverse events after the implementation of an intervention that involved a structured computerized sign-out program (55). Petersen and colleagues proposed a structured computerized cross-coverage sign-out list that would include a summary of the patient’s medical condition, recent laboratory data, resuscitation status, a problem list,



medication allergies, and follow-ups for the efficient transfer of information (55). Inadequacies in the transfer of information can also result from unstructured physician discharge summaries and the time they require to be transferred from inpatient to outpatient providers. Studies have proposed the implementation of standardized discharge summaries (56–58) and the use of structured, database-generated discharge summaries instead of dictation discharge summaries to improve the quality of the information content and to reduce the time required for this information transfer (59). Such improvements in the transfer of information have occurred with the introduction of the computerized medical record in health care systems such as the Veterans Health Administration (60). Other inefficiencies in the transfer of medical information have been identified with the discharge planning process (27). A structured discharge planning process was a key element of an ACE Unit (36). This discharge planning process focused on an early home return, assessment of plans and needs for discharge by a nurse at the time of admission, and early involvement of a social worker and home nurse if indicated (36). We propose that a comprehensive discharge planning process should also include a trained discharge manager present at all hospital discharges. A discharge manager would be responsible for transferring all discharge information to patients or family members, such as a list of medications and follow-up physician visits, laboratory tests, and medical procedures. Also, a discharge manager would provide a seamless transition of care to a rehabilitation center. Thus, a comprehensive discharge process would assure both the hospital and the patient that all necessary information was provided and well understood prior to discharge.

geriatrics care unless the system is appropriately structured. Advocating for such a system is not easy and requires advocacy and management skills that are not part of current geriatrics training programs. Instruction in geriatrics training programs should also emphasize the recommendations mentioned here and continue to emphasize skills in patientcentered care and evidence-based practice. The integration of new recommendations and existing skills in geriatric fellowship programs will enhance the implementation of safety practices and avert geriatric syndromes.

Reducing Adverse Drug Events An estimated 1 million hospitalized patients are affected annually from adverse drug events (61–63). An immediate initiative is to implement computerized physician order entry (CPOE) and computerized medication alert monitors. The Leap Frog Group for Patient Safety has been in the forefront for advocating the implementation of CPOE in hospitals and specifying that these systems have reduced prescribing errors by more than 50% (64,65). Several studies have demonstrated that CPOE and computerized alert monitors will be effective and imperative for reducing the rate of potential adverse drug events (65–70). The implementation of CPOE and computerized alert monitors will especially benefit elderly patients where adverse drug events are most common (5,7,16). The prevention of adverse drug events should not be limited to hospital and nursing home patients, but should also include home care patients that may be at risk for polypharmacy. A recent study suggested that polypharmacy should be considered a marker for older home care patients at risk for hospitalization (71). Thus, a careful attention to the prevention of adverse drug events in elderly people is required in all venues of care.


Improving Geriatric Training Programs As described above, no matter how clinically skilled physicians may be, they will not be able to provide optimal

Conclusion It is our contention that geriatrics should be recognized as a patient safety specialty. We have demonstrated a strong link between geriatrics and patient safety and a clearly defined need to enhance care for elderly patients. Enhanced care can be achieved by adopting well-established safety recommendations such as the ones mentioned here to reduce the occurrence of medical errors. Once these safety recommendations have been adopted and effectively implemented, the occurrence of geriatric syndromes will be reduced. Geriatricians should realize that these safety recommendations are critical in improving the quality of geriatric care.

ACKNOWLEDGMENT Address correspondence and reprints to Dionyssios Tsilimingras, MD, MPH, Center for Health Quality, Outcomes, and Economic Research, Bedford VAMC (152), 200 Springs Road, Bedford, MA 01730. E-mail address: [email protected] or alternate corresponding author Dan R. Berlowitz, MD, MPH, Center for Health Quality, Outcomes, and Economic Research, Bedford VAMC (152), 200 Springs Road, Bedford, MA 01730. E-mail address: [email protected]

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Received March 21, 2003 Accepted April 22, 2003