Reducing harm in long-term care

Frank Mazza
Frank Mazza

Between 210,000 and 440,000 hospital patients die each year from some type of preventable harm – the nation's third-leading cause of death. While no analogous assessment of mortality risk due to error has yet been established for the long-term care setting, it is a safe bet that errors and adverse events also occur within long-term care facilities to a similar extent as they do in hospitals.

The reason for this is that harm to patients does not stem from specific characteristics of the patient population served, but rather from imperfectly designed systems of care, despite best efforts, and because the individuals who work within those systems function imperfectly.

One key to favorably influencing safety of care is to enhance human performance in care environments. This includes doing everything possible to prevent errors in the first place by making available the best possible technology, policies and procedures. Even under optimal conditions, however, errors and adverse events occur because of human factors, such as fatigue, distraction, stress and cognitive bias. Similarly, healthcare system policies and procedures are subject to mistakes in execution because of “latent pathogens” that serve as the holes in the so-called “Swiss cheese” model used as the paradigm for error and harm.  

When "near misses" and incidents of harm are both considered, the sheer number of events that are logged on a given day or week in a healthcare facility can be staggering.  No single institution commands the breadth and depth of resources necessary to fix all error-prone processes at one time. The first step toward improving this situation is to adopt an incident reporting system (IRS).  

How incident reporting systems work

Data collected in incident-reporting systems can be easily aggregated and periodically prioritized for performance improvement initiatives based upon the degree of harm experienced (severity-based) or the frequency of occurrence (volume-based).

Consider this: The widespread adoption of an incident reporting system for Near Miss events enabled the airline industry to become “highly reliable” and operationally ultra-safe, to the point where there is now only one death by crash for every 100,000,000 passengers.

To achieve a comparable result in healthcare, event-reporting systems must duplicate this kind of success. These systems must be easy to use, requiring no more than a few minutes to enter an event, and have a way to triage events for further investigation.  

Ideally, further classification and categorization should be left to those trained in accident investigation. In short, by way of the appropriate use of event reporting in long-term care, it's possible to get one step closer to the prospect of ultra-safe healthcare.

Frank Mazza is the chief medical officer at Quantros.

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