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

Dominika Kohanová,Martina Lepiešová ,Daniela Bartoníčková,c ,Pavol Faťun ,Katarína Žiaková

aDepartment of Nursing, Faculty of Social Sciences and Health Care, Constantine the Philosopher University in Nitra, Nitra 94901, Slovak Republic

bDepartment of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin 03601, Slovak Republic

cDepartment of Nursing, Faculty of Health Sciences, Palacký University in Olomouc, Olomouc 77515, Czech Republic

Abstract: Objective:This systematized review aimed to synthesize the results of empirical studies focused on the types and factors of adverse events (AEs) that contribute to them in long-term care (LTC) settings.Methods:The search was conducted in ProQuest,Scopus,and PubMed in January 2021 and resulted in 1057 records.The content analysis method was used in the data analysis.Results:In all,35 studies were identified as relevant for the review.The analysis revealed 133 different types of AEs and 60 factors that contributed to them.Conclusions:In LTC,various AEs occur,most of which are preventable,while many factors that influence their occurrence could be significantly modifiable.Through an effective analysis of AEs in LTC,it is possible to minimize their occurrence and,at the same time,minimize their negative impact on all parties concerned.

Keywords: adverse event • facility • factors • long-term care, healthcare workers

1.Introduction

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.1The 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.2AEs 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.3Elderly 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.4One 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.5Unfortunately,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.6Furthermore,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.7Studies 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.8Among the AEs that most jeopardize residents’ safety,pressure ulcers and infections could be evidenced in LTC facilities more recently.9–11Less 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.10Many AEs are the result of inadequate or rationed nursing care.4In 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.13However,older people perceive these manifestations more sensitively,leading to increased social isolation and loneliness,a decreased quality of life,and premature death.14Furthermore,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.15,16Compromised 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,17identifying interventions for prevention18–21or examining the specific AEs,such as falls22or medication errors.23Furthermore,Okpalauwaekwe and Tzeng3in 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.

2.Methods

2.1.Aim

This systematized review aimed to collate the existing empirical research literature on AEs in LTC facilities,to describe the types of AEs and factors that contribute to them in LTC facilities.The aim was specified by the following research questions:

1.What methods were used to study AEs in LTC facilities?

2.What types of AEs occur in LTC facilities?

3.What are the factors that affect the occurrence of AEs in LTC facilities?

2.2.Design

A systematized review design was selected,with the inclusion criterion that AEs are the key target of the reviewed studies.A systematized review allows following a systematic approach to search,retrieve,extract,and analyze the available literature without excluding studies based on their methodological quality.24The systematized review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist (PRISMA checklist).25

2.3.Search protocol

The search was carried out in January 2021 in 3 scientific databases,PubMed,ProQuest,and Scopus,based on their institutional availability.The search was carried out using both mesh terms and different combinations of keywords that refer to AEs and LTC.The search is shown in Table 1.The search was limited to language (English);however,no time limits were determined.The predefined criteria were stated.The study was included if it: (a) was an empirical study (qualitative,quantitative,mixed-method);(b) was published in a peer-reviewed journal;(c) was published in the English language;(d) focused on the topic of interest(AEs in LTC facilities,e.g.,nursing home,residential facility,old age home);(e) involved residents (65 years and older),family relatives,direct care workers,facility managers;and (f) the care was provided for at least 1 month in the LTC facility.On the contrary,the study was not included if it: (a) involved social or administrative workers;(b) was carried out in home care settings;and (c) was a review study,discussion article,editorial,or commentary.

Table 1.The search process in scientific databases PubMed,Scopus,and ProQuest.

2.4.Study retrieval

Based on predefined criteria,the data were systematically retrieved by two independent researchers (DK,PF) within two retrieval phases.The search and retrieval process reflected the recommendations of PRISMA(Figure 1).25The program Rayyan QCRI®26(Rayyan Systems,Inc) was utilized to retrieve studies effectively in both retrieval phases.The search produced 1057 studies (220 from Scopus,402 from ProQuest,and 435 from PubMed).After removing duplicates (n=112),945 studies were analyzed through titles and abstracts and examined against inclusion and exclusion criteria.In this phase,917 studies were excluded because they did not directly relate to the stated research questions.In the second retrieval phase,37 studies were examined by reading full-texts.The second phase resulted in 35 studies included in further analysis.Two studies were excluded because they did not meet the inclusion criterion (the provision of care for at least 1 month).

Figure 1.PRISMA flow diagram.PRISMA,Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

2.5.Data extraction and analysis

Data extraction of studies included in the scoping review was performed by two independent researchers(DK,PF).Data were extracted using a spreadsheet in Microsoft Excel,which included the following information: author,year,country,design,sample (size and targeted respondents),data collection,data analysis,and facility type.Data were analyzed by the content analysis method,according to the specific methodology of Mayring.27 The analysis resulted in the logical categorization of data.The main benefit of using this methodology is comprehensiveness.The methodological process consists of 8 specific steps.The results are presented narratively and in tables to address the defined research questions.The research team discussed data condensed and charted in tables and double-checked accuracy (10% of the material).Types of AEs and the contributing factors were identified from the studies in the results sections,tabulated,and then categorized.Expressions and language used by the study participants and study authors were used in the analysis to reduce interpretation.

3.Results

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).

Table 2.Characteristics of the included studies.

3.1.Resources and methods of collecting data in the analyzed studies

The resources used most frequently to investigate AEs were reports from various types of reporting systems.Other methods included specific instruments evaluating AEs,but also resident records,interviews,or population-based administrative databases.All methods are reported in Table 3.

Table 3.Resources and methods of collecting the data in analyzed studies.

The prevalence of AEs was examined in studies during different periods.Most commonly,they focused on the short evaluation period,ranging from 3 months to 12 months.29,38,49,56Likewise,some studies focused on evaluating AEs in the past few years,ranging from 2 years30,51to a maximum of 5 years.35

3.2.Types of AEs in LTC facilities

Based on the content analysis,133 different types of AE were identified in LTC facilities.AEs were categorized into those related to physiological functioning (Table 4)and those related to psychological functioning (Table 5).

Table 4.AEs impacting physical functioning in LTC facilities.

3.2.1. AEs impacting physiological functioning

Concerning the category of AEs that affect physiological functioning,107 different types of AEs were identified in the LTC facilities.The most prominent and,at the same time,the most frequently reported AEs were falls,35,56,62 primarily falls with injury.43,50,53Falls comprised 63.9% of all AEs in the study by Shmueli et al.55from which the most frequently reported were falls while walking (42.3%) and falls from the bed (27.0%).Kapoor et al.42reported that 52.0% of AEs were represented by falls with injury and occurred during care provision.In addition,87.8% of the AEs reported were preventable.The second most common AE in LTC facilities were pressure ulcers.28,45,57In most studies,pressure ulcers were considered as preventable AEs.42However,in these studies,only little information was reported on specifications related to the stages or locations of pressure ulcers in residents.For example,Kapoor et al.43considered pressure ulcers at any stage,while authors in the study by Van Gaal et al.57considered pressure ulcer as present if a patient developed a pressure ulcer Category 2 or worse,according to the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (EPUAP/NPUAP) classification system.Other important AEs were medication errors,29,46,58mainly in terms of adverse drug reactions,48administration of incorrect doses,32or insufficient monitoring of residents after application of the medication.38In the study by Andersson et al.,29medication errors involved 37.0% of all AEs.Crespin et al.32found that administration of incorrect doses represented 56.5% of all medication errors and was the most prevalent type of these errors.In addition,most medication errors occur during the course of medication administration (49.1%)or in the prescribed treatment documentation (38.8%).According to the results of Gurwitz et al.38,medication errors occur more frequently during the daily shift,between 7 AM and 3 PM.The least frequently reported AEs in LTC facilities were hemorrhagic complications38,42and respiratory problems.42,45

3.2.2. AEs impacting psychological functioning

Within the category of AEs related to psychological functioning,26 different types of AEs were identified in the LTC facilities.The most dominant and frequently reported AE was resident’s agitation47,51 and pain,31,45including back pain and pain in the extremity.45In the Oliveria et al.study,51agitation occurred in 27.6% of the residents and was one of the most prevalent AEs in residents with Alzheimer’s disease and psychosis.In the Gerety et al.study,36agitation was classified in 17% of residents as an adverse drug event.Alarmingly,violence and abuse of residents were reported as AEs in several LTC facilities.55,60According to Shmueli et al.,55violence (staff to patient,patient-to-patient,patient-to-staff,family-to-patient or staff) was the second most reported AE.The unplanned hospitalization,37,50respectively,urgent emergency visits due to an unexpected complication in the resident’s health status were other AEs54impacting the psychological functioning of the residents,primarily in terms of their decreased satisfaction.In contrast,personality change,45escape of resident,62selfinjury,55or depression (as an adverse drug event)45were the least frequently reported AEs in the LTC facilities.

3.3.Factors contributing to AEs

Based on the content analysis,60 factors that contribute to AEs in LTC facilities were identified.These factors were categorized into two meaningful groups: organization-related and resident-related factors.

3.3.1. Organization-related factors that contribute to AEs

Within organization-related factors,45 factors were determined in the analyzed studies.The most significant factor was the inadequate number of healthcare professionals,48,58 especially nurses28,39and physicians.37The shortage of healthcare professionals represents the global problem that significantly affects patient care quality and safety,primarily in the context of the occurrence of AEs.47Another important identified factor was the lack of a patient safety culture in LTC facilities,28,53especially in terms of punitive responses,39ineffective leadership,and inadequate support from the manager responsible for safety.39,53Moreover,the work environment considered as unsafe contributed similarly to AEs in LTC facilities.32,53On the contrary,if the patient’s safety culture was considered positive and adequate,the LTC facilities reported fewer AEs,such as falls,pressure ulcers,and urinary tract infections.28Other contributing factors were insufficient competence of healthcare professionals,37,47higher licensed practical nurse hours per resident day compared with registered nurses hours,28,55the insufficient time needed for the provision of necessary nursing care activities37,58and inadequate work conditions32,58including ineffective work organization,47insufficient resources necessary for the provision of fundamental or specific nursing care,32,47and ineffective teamwork.29,39Furthermore,the workload of nurses was identified as another significant factor that may lead to AEs.32,37,39,58Similarly,there was evidence that healthcare professionals in LTC facilities face several challenging situations that contribute significantly to AEs.One of them is the premature transfer of residents without completing treatment from the hospital to LTC.37Furthermore,a high number of residents per nurse in LTC58,62has been determined as the factor that contributes to the higher incidence of urinary tract infections.28Furthermore,a higher incidence of AE was shown to be related to insufficient financial resources37,39as well as the type and size of the LTC facility.48More AEs have been reported in nursing homes and facilities with a bed capacity of over 60 beds.48,62Interestingly,a higher number of AEs were also reported during night shifts.30Frequently reported contributory factors were inadequate knowledge or skills related to care provision or insufficient experience of care workers,47,62but also the prevalence of missed nursing care,29,47which relates to the non-adherence to processual standards of care47,58and suboptimal provision in assessing and monitoring of residents’ health status29,47,49and teaching or prevention.29,49Factors such as unwillingness to accept best practices or to change care workers’ behavior and performance,39decreased job satisfaction,37and emotional exhaustion32,37,39also lead to AEs in LTC facilities.Another contributing factor raising ethical issues is the unnecessary use of physical restrictions in the care of residents.30,48

3.3.2. Resident-related factors contributing to AEs

Within the category of resident-related factors,16 factors were identified.The most frequently described factor was the use of medications,which often resulted in residents’ falls.31,45Similarly,the risk of AEs was potentiated by polypharmacy36,44but also increased use of antibiotics or psychotropic drugs.33,48Another significant factor was the age of the residents.In the group of residents <75 years old,more AEs were reported compared with younger residents.30,33A meaningful group of factors that contribute to AEs related to the health status of residents.The highest number of AEs was reported in residents with decreased ability of self-care,33,43decreased or impaired mobility,34,35,44cognitive deficits,32,44chronic diseases,33,35and polymorbidity.36,37Falls were the most commonly reported in residents with decreased mobility,where pressure ulcers were reported as the result of several affecting factors,such as a higher age of residents,decreased mobility,and polypharmacy.44Interestingly,more AEs were reported in male residents.30

4.Discussion

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,3while earlier studies on AEs were limited to specific setting17or focused on the specific AE22or intervention.21Our 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.63Poor quality of care can be attributed to multiple AEs that negatively affect residents’ safety.64Furthermore,the number of AEs in LTC facilities is significantly higher compared with acute care facilities.3For 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.65AEs 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.2who 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,2,66inadequate 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.16In 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.63An effective skill mix should be established to achieve the best outcomes,but an effective delegation among direct care workers should also be adjusted.67Furthermore,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 Kalánková et al.,4who 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.68,69Clear 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 workers47together with missed nursing care29as 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.2This 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.,70direct 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.11,68,71Furthermore,failure to act when necessary is associated with missed nursing care and,similarly,with various types and severity of AEs in LTC facilities.4Recently,missed nursing care in community health settings has been reviewed in the study of Andersson et al.,72who attributed missed nursing care to AEs.Other factors contributing to AEs,reported by Andersson et al.2and Wang et al.69involve 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 professionals2without 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,44also supported by the study of Cloete.73In 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.31The age of the resident is an important factor contributing to AEs,more specifically if the resident is <75 years old.Several authors13,14supported 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.35,44Similarly to our findings,Palese et al.74stated 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

4.1.Limitations

The systematized review has several limitations.The first limitation is the inclusion of studies published exclusively in English.Additionally,the number of scientific databases used in the literature search depended on institutional accessibility,therefore some relevant studies could be omitted.In contrast,the selected review design enabled the collation of an extensive number of empirical studies and,at the same time,deepening our understanding of the literature.

5.Conclusions

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.

Author contribution

All listed authors confirm that they participated in the development of the manuscript in the following ways:conception and design or analysis and interpretation of the data;drafting the article or revising it critically for important intellectual content,and final approval of the version to be published.

Ethical approval

Ethical issues are not involved in this paper.

Conflicts of interest

All contributing authors declare no conflicts of interest.