Investigating adverse events in long-term care facilities: a systematized review

Adverse events (AEs) are significant indicators of quality of care and patient safety. In the literature, AEs are defined in many ways, most often as unintended injuries or complications related to the management of healthcare provision and, at the same time, result in patient mortality, disability, unplanned, or prolonged hospital stay.¹ The definitions of AEs largely reflect physical harm or injury to the patient. However, the patient’s living experience is considered in broader definitions. An AE could be understood as suffering, physical or emotional impact, illness, or death, in which many of these consequences could be preventable if necessary actions were adopted during direct patient contact with healthcare givers.² AEs occur in all healthcare systems, whereby the risk of their occurrence increases with the number of surgeries, examinations performed, or applied treatment. Moreover, in addition to direct harm to patients, AEs are a financial burden to any health system.¹

Given the current trend of an aging population, long-term care (LTC) is becoming more and more important. The occurrence of AEs is higher in LTC facilities compared with acute care facilities.³ Elderly patients, respectively, residents of LTC facilities, are at increased risk of AEs due to deterioration of their health status, polymorbidity, and reduced contact with relatives.⁴ One of the critical aspects of improving resident safety is an AE reporting system, which includes identifying AEs and their underlying causes and contributory factors. Reporting AEs also supports safe and quality care.⁵ Unfortunately, due to various barriers to reporting AEs, such as fear of punishment, lack of organizational support, or lack of motivation to report AEs, the number of reported events is much lower than the number that occurs.⁶ Furthermore, no recommended reporting system is recognized internationally; therefore, there are discrepancies in reporting AEs in different countries. It is necessary to raise awareness of various methods to effectively report AEs, even for the management of LTC facilities.⁴

Research on AEs in LTC facilities has focused primarily on falls and medication errors.⁷ Studies of medication errors, including overdosing, have been justified by the belief that residents of LTC facilities are exposed to more errors due to the increased use of medications and that such patients are more vulnerable to the potential consequences of these errors. These studies also highlighted adverse drug events as a frequent problem in LTC facilities.⁸ Among the AEs that most jeopardize residents’ safety, pressure ulcers and infections could be evidenced in LTC facilities more recently.^9–11 Less frequently reported AEs, which threaten residents, are preventable death, fractures, impaired nutritional status, dehydration, or accidental injuries.^9,10,12

Most reported AEs, which lead to deterioration in the physical or mental health of residents, are the result of neglecting fundamental nursing care activities, such as turning, feeding, hygiene care, or surveillance.¹⁰ Many AEs are the result of inadequate or rationed nursing care.⁴ In addition, other factors contribute to AEs in LTC facilities, and poor training of healthcare professionals is one of the most critical. Healthcare professionals in LTC frequently use manipulation, infantilism, raised voices, insults, or quarrels in communication with residents.¹³ However, older people perceive these manifestations more sensitively, leading to increased social isolation and loneliness, a decreased quality of life, and premature death.¹⁴ Furthermore, the values of healthcare professionals, the loss of empathy, professionalism, or freedom to share opinions with the manager, followed by burnout syndrome and emotional exhaustion, but also insufficient knowledge or skills might lead to compromised care, which often results in errors or AEs during the care provision.^15,16 Compromised care is also associated with organizational factors, such as inadequate staff numbers, ineffective work organization, inadequate teamwork, and inappropriate work conditions that may also contribute to AEs as well.^10,11

Recent reviews have focused on the topic (AEs and contributing factors), especially in home care,¹⁷ identifying interventions for prevention^18–21 or examining the specific AEs, such as falls²² or medication errors.²³ Furthermore, Okpalauwaekwe and Tzeng³ in their scoping review, analyzed the contributory factors to AEs among older adults during short stays in skilled nursing facilities and found extrinsic contributors related to capacity and opportunity, shedding light on areas that warrant further research. AEs in LTC remain hidden problems and are still overlooked. Considering the trend of the aging population, AEs and their contributing factors should be noted and summarized to be addressed by the management of LTC facilities, in order to improve the safety of residents and improve the quality of care in these facilities. Therefore, our review focuses on LTC, including rehabilitation, curative, nursing, or palliative care; reports how AEs were studied in the literature; and analyzes various types of AEs along with factors that may influence their occurrence in LTC facilities.

The systematized review included 35 studies that reflected the types of AE and the factors that contribute to them in LTC facilities (Table 2). Most of the studies analyzed were conducted in the United States (n = 16), followed by several European countries, such as Sweden (n = 5), Norway (n = 2), or the Netherlands (n = 2). Several studies were conducted in Canada (n = 4). Regarding the design of the study, most of the studies were quantitative in nature (n = 29). Most studies were carried out in nursing homes (n = 22) or in combination with other area (n = 4). In the remaining cases the LTC facilities were not specified (n = 9).

Our systematized review aimed to collect empirical evidence focusing on the types of AE and factors that contribute to them in LTC facilities. Existing evidence on AEs highlighted the need for further research on the topic,³ while earlier studies on AEs were limited to specific setting¹⁷ or focused on the specific AE²² or intervention.²¹ Our review takes a broader approach to AEs in LTC facilities to capture generic but recurring safety issues. We identified 131 types of AEs and 60 factors that contribute to them in LTC facilities.

With the increasing trend of an aging population, the number of LTC facilities also increases. However, the quality of care in these facilities is often reported as poor.⁶³ Poor quality of care can be attributed to multiple AEs that negatively affect residents’ safety.⁶⁴ Furthermore, the number of AEs in LTC facilities is significantly higher compared with acute care facilities.³ For example, in the USA, estimates of the harm rate were determined for 46% in LTC, while the prevalence of AEs in acute care facilities was identified to be 27%. Alarmingly, up to 21% of residents experience AEs in LTC facilities every year.⁶⁵ AEs in LTC facilities represent a significant problem, but data related to AEs on a national level from Europe, Asia, Africa, or other continents are only sporadically reported. Therefore, identifying AEs and exploring contributing factors is crucial to improve quality of care and residents’ safety.²

The main group of factors was related to organization (system factors) in our review, which is in line with the study of Andersson et al.² who identified 18 factors that contribute to AEs and most of which were related to system factors. Furthermore, system factors have the potential to trigger active errors or errors, leading to serious AEs, often resulting in a resident’s disability or unexpected death. In line with international studies,^2,66 inadequate healthcare professionals, lack of time, and inadequate working conditions were the most dominant factors in this category. The inadequate number of healthcare professionals is a global problem that directly jeopardizes patient safety and quality of care and is also evidenced in LTC facilities.¹⁶ In addition, emphasis should be placed on ensuring a careful balance between licensed practical nurses and registered nurses. This seems to play a significant role in ensuring the quality of care in LTC facilities.⁶³ An effective skill mix should be established to achieve the best outcomes, but an effective delegation among direct care workers should also be adjusted.⁶⁷ Furthermore, the inadequate number of healthcare professionals is related to the insufficient time to provide the necessary nursing care activities. Our findings are consistent with the study of Kalankova et al.,⁴ who identified that time scarcity has a direct and negative impact on AEs related to the care of residents. We identified that inadequate work conditions relate to the work organization, ineffective teamwork, and inadequate communication within the team, and directly lead to the risk of AEAEs. Likewise, an unsafe work environment with a missing patient safety culture demonstrably threatens the safety of residents.^68,69 Clear and effective communication, particularly when sharing resident information within a team and empowered teamwork, is needed to reduce the risks of AEs in LTC facilities.⁶⁵

Furthermore, we acknowledged inadequate knowledge, skills, or experiences of care workers⁴⁷ together with missed nursing care²⁹ as other meaningful factors. Inadequate knowledge, skills, or experiences are reflected particularly in situations where no necessary action was taken when the resident ‘s condition deteriorated.² This is a common situation where registered nurses do not work on shifts. The possible explanation for these findings could be related to the inadequate skill mix of healthcare professionals, but also to insufficient competence to ensure safe care. According to Bing-Jonsson et al.,⁷⁰ direct care workers in Norwegian nursing homes had insufficient competence to provide the necessary nursing care activities, leading to a higher incidence of AEs. Direct care workers had no competence in assessment, monitoring of residents, and documentation. Additionally, the reluctance of healthcare professionals to obtain up-to-date knowledge, accept best practices, or change the behavior and performance of healthcare workers could explain the appearance of AEs in LTC facilities.^11,68,71 Furthermore, failure to act when necessary is associated with missed nursing care and, similarly, with various types and severity of AEs in LTC facilities.⁴ Recently, missed nursing care in community health settings has been reviewed in the study of Andersson et al.,⁷² who attributed missed nursing care to AEs. Other factors contributing to AEs, reported by Andersson et al.² and Wang et al.⁶⁹ involve non-adherence to care standards and errors in resident documentation, which correspond to the findings of our systematized review. Given the needs of the residents for comprehensive care, it is reasonable to assume that their safety depends on direct care workers. Furthermore, correct record keeping in documentation is also necessary for sharing information between residents, their relatives, and caregivers, including licensed practical nurses, registered nurses, and other healthcare professionals² without misunderstandings. This highlights the importance of documentation in terms of communicating safe nursing care.

In addition, we identified resident-related factors that affect the occurrence of AEs. These factors reflect mainly the characteristics of the residents, such as age, gender, or health condition, rather than their behavior or attitudes toward care workers or direct caregivers. In our systematized review, medication use, age, and health status were the most significant factors related to residents. We identified that polypharmacy is the most important contributing factor to AEs,⁴⁴ also supported by the study of Cloete.⁷³ In LTC facilities, regular medication review and careful consideration of prescription and administration of additional medication should become an effective strategy to reduce AEs associated with medication use.³¹ The age of the resident is an important factor contributing to AEs, more specifically if the resident is <75 years old. Several authors^13,14 supported our findings and declared that age-related AEs in LTC facilities are associated mainly with the manifestation of ageism, such as infantilism, insulting, arguing, or manipulative behavior or actions toward residents. We also found that residents experiencing physical or psychological deterioration, such as impaired mobility or cognitive deficit, were at a greater risk of AEs than self-sufficient residents or those with no cognitive deficit.^35,44 Similarly to our findings, Palese et al.⁷⁴ stated that the most jeopardized group of residents in terms of AEs are those with a cognitive deficit, specifically the severe form of dementia. Based on our findings, we can conclude that most of the characteristics of residents that contribute to AEs are somehow associated with the phenomena of ageism. The consequences of ageism are compelling for the elderly, especially in terms of AEs. The principles of care provision in LTC facilities should meet residents’ fundamental rights to respectful and dignified care. If care provision does not comply with the fundamental rights and values, serious ethical issues arise, especially in the case of harm to residents.⁴

AEs and factors contributing to them in LTC facilities represent the problem with insufficient attention paid in international or national contexts. Several research studies conducted in the European context are minimal. The healthcare professional communities must be aware that elderly patients and residents are most vulnerable compared with other group of patients due to their vulnerability due to higher age, polypharmacy, and physical or mental deterioration. Considering the trend of the aging population, nursing research should focus on identifying factors that contribute to AEs in LTC facilities followed by consequent planning and implementation of strategies aimed at reducing AEs. The main gaps in the determination of factors that condition AEs that are commonly modifiable could contribute to considerable problems in the prediction and effective settings of preventive measures. Managers of LTC facilities should consider implementing systematic measures, since most AEs are preventable. Measuring the rates of AEs in LTC facilities should be considered a priority health policy issue. The systematized review has raised implications for nursing care that calls for further research, mainly for precise identification, close monitoring, reporting, and documenting AEs in LTC facilities. More quantitative, qualitative, and mixed-method research studies should focus on various targeted groups, including residents and their relatives, as AEs affect them the most, but research in the future should also involve managers, caregivers, and policymakers to obtain comprehensive evidence on AEs in LTC facilities. Another review could also focus on the frequency comparison of these events as well, as it should cover other areas of care provided. The main challenge is to develop such reporting systems that eliminate the fear of reporting AEs and promote a non-blaming culture and just culture in LTC facilities.