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

Dominika Kohanová
Dominika Kohanová
, 
Martina Lepiešová
Martina Lepiešová
, 
Daniela Bartoníčková
Daniela Bartoníčková
, 
Pavol Faťun
Pavol Faťun
 oraz 
Katarína Žiaková
Katarína Žiaková
   | 18 gru 2023
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Article Category: Review
Data publikacji: 18 gru 2023
Zakres stron: 399 - 412
Otrzymano: 28 sty 2023
Przyjęty: 21 mar 2023
DOI: https://doi.org/10.2478/fon-2023-0043
Słowa kluczowe
© 2023 Dominika Kohanová et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Figure 1.

PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Characteristics of the included studies.

Study, country Study design Sample Data collection Data analysis Facility type
Abusalem et al.28, USA Quantitative, crosssectional N = 252 direct care workers Questionnaire Descriptive and inferential statistics Non-specified
Andersson et al.29, Sweden Quantitative, retrospective N = 173 reports AEs reports Content analysis, descriptive statistics Nursing home
Aranda-Gallardo et al.30, Spain Quantitative, prospective N = 647 residents Questionnaire Descriptive and inferential statistics Nursing home
Boockvar et al.31, USA Quantitative N = 122 residents Residents’ documentation Descriptive and inferential statistics Nursing home
Crespin et al.32, USA Quantitative, cross-sectional N = 15 037 reports AEs reports Descriptive and inferential statistics Nursing home
Daneman et al.33, Canada Quantitative, cohort N = 110 656 residents AEs reports Descriptive and inferential statistics Nursing home
Djikstra et al.34, Netherland Quantitative, crosssectional N = 13 633 residents Questionnaire Descriptive and inferential statistics Nursing home
Doupe et al.35, Canada Quantitative, cohort N = 22 846 residents Administrative data Descriptive and inferential statistics Nursing home
Gerety et al.36, USA Quantitative, retrospective N = 175 residents Residents’ documentation Descriptive and inferential statistics Nursing home
Glette et al.37, Norway Qualitative, comparative N = 17 nurses and nurse managers Semi-structured interviews Content analysis Nursing home
Gurwitz et al.38, USA Quantitative, retrospective N = 490 residents Residents’ documentation Descriptive and inferential statistics Nursing home
Halligan et al.39, Canada Mixed method N = 26 direct care workers Questionnaire, semistructured interviews Descriptive statistics; content analysis Non-specified
Herrmann et al.40, Canada Quantitative N = 24 residents Questionnaire Descriptive and inferential statistics Non-specified
Hughes et al.41, USA Quantitative, retrospective N = 8267 residents Questionnaire Descriptive and inferential statistics Nursing home
Kapoor et al.42, USA Quantitative, prospective N = 555 residents Residents’ documentation Descriptive and inferential statistics Non-specified
Kapoor et al.43, USA Quantitative, prospective N = 555 residents Residents’ documentation Descriptive and inferential statistics Nursing home
Lannering et al.44, Sweden Quantitative, longitudinal N = 429 residents Questionnaire Descriptive and inferential statistics Nursing home
Lexow et al.45, Germany Quantitative, crosssectional N = 104 residents Interviews, residents’ documentation, medication analysis Descriptive and inferential statistics Non-specified
Lindblad et al.46, Sweden Quantitative, retrospective N = 518 records Residents’ documentation Descriptive and inferential statistics Nursing home
Lindblad et al.47, Sweden Quantitative, retrospective N = 600 records Residents’ documentation Descriptive and inferential statistics Nursing home
Lombardo et al.48, Italy Quantitative N = 1356 residents Questionnaire Descriptive and inferential statistics Nursing home
McDonald et al.49, USA Quantitative N = 50 residents Residents’ documentation Descriptive and inferential statistics Nursing home
Niznik et al.50, USA Quantitative, retrospective N = 37,106 residents Residents’ documentation Descriptive and inferential statistics Nursing home
Oliveria et al.51, USA Quantitative, retrospective N = 7728 residents Questionnaire Descriptive and inferential statistics Nursing home
Prang and Jelsness-Jorgensen52, Norway Qualitative N = 13 nurses Semi-structured interviews Thematic analysis Nursing home
Quach et al.53, USA Quantitative, crosssectional N = 56 nurses Questionnaire Descriptive and inferential statistics Nursing home, community center
Resnik and Galik54, USA Secondary analysis N = 199 residents Questionnaire Descriptive and inferential statistics Nursing home, residential care
Shmueli et al.55, Israel Quantitative, descriptive N = 1364 reports AEs reports Descriptive and inferential statistics Non-specified
Trinks et al.56, Sweden Quantitative, retrospective N = 40,224 residents AEs reports Descriptive and inferential statistics Nursing home, hospital
Van Gaal et al.57, Netherland Quantitative, prospective N = 687 patientsN = 241 residents Residents’ documentation Descriptive and inferential statistics Nursing home, hospital
Wagner et al.58, USA Quantitative, crosssectional N = 289 nurses Questionnaire Descriptive and inferential statistics; content analysis Non-specified
Wagner et al.59, USA Quantitative N = 399 managers of nursing homes Questionnaire Descriptive and inferential statistics Nursing home
Wagner et al.60, USA Quantitative N = 32 states; healthcare departments Questionnaire Descriptive and inferential statistics Nursing home
Wang et al.61, Australia Quantitative, casecontrol N = 332 casesN = 332 controlled cases Residents’ documentation Descriptive and inferential statistics Non-specified
Yu and Perng62, Taiwan, China Quantitative, crosssectional N = 213 nurse aids Questionnaire Descriptive and inferential statistics Non-specified

AEs impacting physical functioning in LTC facilities.

AEs impacting physical functioning Examples of references
FallsFalls with Injury; Falls while walking; Falls from bed; Witnessed falls; Resident found on the floor Abusalem et al.28; Andersson et al.29; Aranda-Gallardo et al.30; Doupe et al.35; Herrmann et al.40; Kapoor et al.42; Kapoor et al.43; Lannering et al.44; Lexow et al.45; Lindblad et al.46; Lindblad et al.47; Lombardo et al.48; Prang and Jelsness-Jorgensen52; Quach et al.53; Resnick and Galik54; Shmueli et al.55; Trinks et al.56; Van Gaal et al.57; Wagner et al.58; Wagner et al.60; Yu and Perng62
Pressure ulcersNot specified Abusalem et al.28; Dijkstra et al.34; Doupe et al.35; Kapoor et al.42; Kapoor et al.43; Lannering et al.44; Lexow et al.45; Lindblad et al.46; Lombardo et al.48; Quach et al.53; Trinks et al.56; Van Gaal et al.57; Wagner et al.60; Yu and Perng62
Medication errorsAdverse reactions of medications (Medication interactions; Affected laboratory values); Wrong dosage (Overdose or underdose); Medication administered to wrong resident (Incorrect identification of resident); Wrong medication administered to the resident; Insufficient follow-up after medication administration;Wrong rate of administration; Improper storage of medications; Prescription – missing or unclear; Wrong route of medication administration; Wrong technique of medication administration; Wrong time of medication administration; Administration of expired medication Andersson et al.29; Boockvar et al.31; Crespin et al.32; Gerety et al.36; Gurwitz et al.38; Kapoor et al.42; Lindblad et al.46; Lindblad et al.47; Prang and Jelsness-Jorgensen52; Shmueli et al.55; Wagner et al.58; Wagner et al.60; Yu and Perng62
InfectionsUrinary tract infection (Prolonged catheter use; Hematuria); Respiratory infections; Multiresistant infections; Conjuctivitis; Surgical/procedural site infection; Skin infection; Vulval infection; Gastroenteritis; Clostridium difficile infection; Infection disease outbreak among residents Abusalem et al.28; Boockvar et al.31; Daneman et al.33; Doupe et al.35; Gurwitz et al.38; Kapoor et al.42; Lexow et al.45; Lombardo et al.48; Oliveria et al.51; Quach et al.53; Van Gaal et al.57; Wagner et al.60
Gastrointestinal problemsVomiting; Nausea; Abdominal pain; Diarrhea; Obstipation; Dehydration; Impaired mouth health; Gastrointestinal bleeding (Blackened stool); Bowel obstruction; Cholelithiasis; Cholecystitis; Malnutrition (Decreased appetite; Weight changes; Abnormal glucose value) Boockvar et al.31; Daneman et al.33; Gerety et al.36; Gurwitz et al.38; Hughes et al.41; Herrmann et al.40; Kapoor et al.42; Lannering et al.44; Lexow et al.45; Lindblad et al.46; Lindblad et al.47; Lombardo et al.48; Oliveria et al.51; Trinks et al.56
Cardiovascular problemsChest pain – cardiac; Palpitations; Hypertension; Exacerbation of health failure; Systemic embolism; Deep vein thrombosis; Pulmonary embolism; Cardiac arrest; Cardiogenic shock; Orthostatic hypotension; Supraventricular tachyarrhythmia; Peripheral oedema Boockvar et al.31; Gerety et al.36; Gurwitz et al.38; Kapoor et al.42; Lexow et al.45; Lindblad et al.46; Oliveria et al.51
Neurological problemsQuantitative disorders of consciousness (Somnolence); Tremor; Sense-organ disorders (eye, ear); Seizure; Stroke; Fatigue; Insomnia Boockvar et al.31; Gerety et al.36; Gurwitz et al.38; Herrmann et al.40; Hughes et al.41; Lexow et al.45; Lindblad et al.46; Oliveria et al.51
Skin problemsBruises; Angioedema; Burns; Alopecia; Hyperhidrosis; Pruritus Herrmann et al.40; Kapoor et al.42; Kapoor et al.43; Lexow et al.45; Lindblad et al.46; Oliveria et al.51; Wagner et al.60; Yu and Perng62
Musculoskeletal problemsGeneral muscle weakness; Impaired walking; Arthritis; Fractures (Hip fractures) Boockvar et al.31; Doupe et al.35; Gerety et al.36; Lexow et al.45; Niznik et al.50; Oliveria et al.51
Hemorrhagic complicationsEpistaxis; Hematoma; Purpura Gurwitz et al.38; Kapoor et al.42; Lexow et al.45; Oliveria et al.51
Respiratory problemsRespiratory failure Kapoor et al.42; Lexow et al.45
Non-categorized:Deterioration in vital signs; Urine incontinence; Distended urinary bladder; Suffocation; Allergic reaction (Urticaria); Deviation from a normal course after invasive procedure/surgical treatment; Accidental injury; Death Daneman et al.33; Gerety et al.36; Gurwitz et al.38; Kapoor et al.42; Lexow et al.45; Lindblad et al.46; Lindblad et al.47; Lombardo et al.48; Niznik et al.50; Oliveria et al.51; Yu and Perng62

AEs impacting psychological functioning in LTC facilities.

AEs impacting psychological functioning Examples of references
Agitation Gerety et al.36; Herrmann et al.40; Kapoor et al.42; Lexow et al.45; Lindblad et al.47; Lombardo et al.48; Oliveria et al.51
PainBack pain; Headache; Pain in extremity Boockvar et al.31; Lexow et al.45; Lindblad et al.46; Lindblad et al.47; Oliveria et al.51
Change in mental status Lindblad et al.46; Lindblad et al.47; Lombardo et al.48; Lexow et al.45
HospitalizationUnplanned visit of emergency Glette et al.37; Gerety et al.36; Lindblad et al.46; McDonald et al.49; Niznik et al.50; Oliveria et al.51; Resnick and Galik54
Alteration in behaviour Lindblad et al.46; Lexow et al.45; Lombardo et al.48
Errors in communication about residents Lindblad et al.46; Lindblad et al.47; Wagner et al.58
Delirium Kapoor et al.42; Lombardo et al.48; Oliveria et al.51
Anxiety Lexow et al.45; Lindblad et al.46; Oliveria et al.51
Suicidal behaviour Andersson et al.29; Wagner et al.60
ViolenceResident-to-resident; Resident-to-staff; Staff-to-resident Shmueli et al.55; Wagner et al.60
Hallucinations Gerety et al.36; Lexow et al.45
Lethargy Boockvar et al.31; Lexow et al.45
Self-injury Shmueli et al.55
Abuse (physical, sexual) Wagner et al.60
Personality change Lexow et al.45
Delays in diagnosis or treatment Kapoor et al.42
Escape of resident Yu and Perng62
Depression Lexow et al.45
Suicide Wagner et al.60

Resources and methods of collecting the data in analyzed studies.

Resources and methods Examples of references
Reporting systems
Centers for Medicare and Medicaid Services Abusalem et al.28; McDonald et al.49; Niznik et al.50
Health and Social Care Inspectorate Andersson et al.29
Medication Error Quality Initiative - Individual Error System Daneman et al. 33
Veterans’ Health Administration Office of Reporting, Analytics, Performance, Improvement & Deployment Quach et al.53
Computerized AE Management System Shmueli et al.55
the Taiwan Patient Safety Reporting System Yu and Perng62
Minimum Data Set Hughes et al.41; Oliveria et al.51
Instruments
The Dutch National Prevalence Survey of Care Problems Djikstra et al.34
The Modified Stanford Patient Safety Culture Survey Instrument Halligan et al.39
Risk assessment tools Lindblad et al.46; Van Gaal et al.57
Trigger tool Lindblad et al.46; Lindblad et al.47
National Survey on AEs Lombardo et al.48
Senior Alert,56 Trinks et al.56
The Communicating about Nursing Error Survey Wagner et al.58
The Survey on AEs,59 Wagner et al.59
The State Incident Reporting Policies and Practices.60 Wagner et al.60
Other methods
Residents’ records Boockvar et al.31; Gerety et al.36; Gurwitz et al.38; Kapoor et al.42; Kapoor et al.43; Wang et al.61
Residents’ records in combination with risk assessment tools Herrmann et al.40
Interviews Glette et al.37; Lexow et al.45; Prang and Jelsness-Jorgensen52
Verification of the record by caregiver and residents themselves Aranda-Gallardo et al.30
Population-based administrative databases Daneman et al.33; Doupe et al.35
Cumulative count of AEs Resnick and Galik54

The search process in scientific databases PubMed, Scopus, and ProQuest.

Search words Hits
(“Care, Long-Term” [Mesh] OR “Long Term Care” [Mesh] OR “Facilities, Residential” [Mesh] OR “Facility, Residential” [Mesh] OR “Residential Facility” [Mesh] OR “Nursing Home” [Mesh] OR “Homes, Nursing” [Mesh] OR “Old Age Homes” [Mesh] OR “Home, Old Age” [Mesh] OR “Homes, Old Age” [Mesh] OR “Old Age Home” [Mesh]) AND (“adverse event*”) PubMed: 435
(“long-term care” OR “long term care” OR “nursing home*” OR “residential facility*” OR “old age home*”) AND (“adverse event*”) Scopus: 220ProQuest: 402
Total 1057
eISSN:
2544-8994
Język:
Angielski
Częstotliwość wydawania:
4 razy w roku
Dziedziny czasopisma:
Medicine, Assistive Professions, Nursing
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