PMID- 38141662
OWN - NLM
STAT- MEDLINE
DCOM- 20240405
LR  - 20240405
IS  - 1538-9375 (Electronic)
IS  - 1525-8610 (Linking)
VI  - 25
IP  - 4
DP  - 2024 Apr
TI  - Contributing Factors to Adverse Events in Long-Term Care Facilities in Ireland, a 
      Content Analysis.
PG  - 633-638.e3
LID - S1525-8610(23)00975-1 [pii]
LID - 10.1016/j.jamda.2023.11.015 [doi]
AB  - OBJECTIVES: There is substantial research on contributing factors to adverse 
      events (AEs) in acute settings. Little is known about AEs in long-term care 
      facilities (LTCFs). Our aim was to identify contributing factors to AEs from 
      LTCFs for older persons and people with disability to inform quality improvement. 
      DESIGN: Content analysis of statutory notifications of AEs from LTCFs using a 
      modified version of the Human Factors Analysis and Classifications System (HFACS) 
      applied to health care. SETTING: A sample of high risk-rated notifications of AEs 
      received by the regulator in 2018 and 2019 was drawn from the Database of 
      Statutory Notifications from Social Care in Ireland (n = 156). METHODS: Two 
      researchers independently analyzed notifications to identify contributing factors 
      using our modified HFACS. The number of factors identified in each level, 
      subcategory, and nanocode of the HFACS was calculated along with percentage 
      representation of factors within notifications and percentage contribution of 
      individual factors to the total number of factors identified. The number and 
      percentage contributions of factors were also calculated, disaggregated by 
      notification type. RESULTS: Contributing factors from all levels of the HFACS 
      were identified. The most common contributing factor was "Resident factors" 
      followed by "Unsafe acts." No contributing factors were attributed to 68 
      notifications (43.6%). Multiple contributing factors were attributed to 45 
      notifications (28.8%). The largest percentage of factors was identified in 
      notifications of serious injuries (27.4%). CONCLUSION AND IMPLICATIONS: It is the 
      responsibility of LTCFs to account for "Resident factors" in system design, risk 
      management, and care plans. Developing systems and processes that identify where 
      residents have higher risk of harm may reduce the occurrence of high-risk events 
      and thus improve resident safety. The large proportion of notifications where no 
      contributing factors were identified suggests the need for improved reflection 
      and reporting from LTCFs and for more specific questions on notification forms.
CI  - Copyright (c) 2023 The Authors. Published by Elsevier Inc. All rights reserved.
FAU - McGrane, Niall
AU  - McGrane N
AD  - Health Information and Quality Authority, Cork, Ireland.
FAU - Dunbar, Paul
AU  - Dunbar P
AD  - Health Information and Quality Authority, Cork, Ireland.
FAU - Keyes, Laura M
AU  - Keyes LM
AD  - Health Information and Quality Authority, Cork, Ireland. Electronic address: 
      loconnor@hiqa.ie.
LA  - eng
PT  - Journal Article
DEP - 20231220
PL  - United States
TA  - J Am Med Dir Assoc
JT  - Journal of the American Medical Directors Association
JID - 100893243
SB  - IM
MH  - Humans
MH  - Aged
MH  - Aged, 80 and over
MH  - *Long-Term Care
MH  - Ireland/epidemiology
MH  - *Health Facilities
MH  - Skilled Nursing Facilities
OTO - NOTNLM
OT  - Adverse events
OT  - care facilities
OT  - long-term care
OT  - older persons
OT  - people with disability
OT  - serious incidents
COIS- Disclosure The authors declare no conflicts of interest.
EDAT- 2023/12/24 09:41
MHDA- 2024/04/05 06:45
CRDT- 2023/12/23 19:23
PHST- 2023/05/26 00:00 [received]
PHST- 2023/11/08 00:00 [revised]
PHST- 2023/11/14 00:00 [accepted]
PHST- 2024/04/05 06:45 [medline]
PHST- 2023/12/24 09:41 [pubmed]
PHST- 2023/12/23 19:23 [entrez]
AID - S1525-8610(23)00975-1 [pii]
AID - 10.1016/j.jamda.2023.11.015 [doi]
PST - ppublish
SO  - J Am Med Dir Assoc. 2024 Apr;25(4):633-638.e3. doi: 10.1016/j.jamda.2023.11.015. 
      Epub 2023 Dec 20.