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Patient Safety

Patient safety is defined by the Institute of Medicine as freedom from injury associated with accidents or medical errors that can occur across the life span. Joshua A. Perper wrote in 1994 that the most vulnerable patients, who are likely to experience the most frequent and severe injuries, include (a) elderly in poor health; (b) persons with chronic disabling conditions or disabilities, and (c) persons hospitalized for long periods of time. Often, a frail elderly patient “fits” into each of these three high-risk categories, increasing risk exponentially. The purpose of this entry is to elucidate the challenge of promoting patient safety for vulnerable elderly populations, depicting unique hazard conditions, and suggesting safety defenses to prevent adverse outcomes.

Challenge of Promoting Patient Safety in Elderly

Patient safety emerged as a national health care priority in 2000, when the Institute of Medicine report, To Err Is Human, was published. Prior to this, errors and adverse events were common but fairly invisible to the public. The Institute of Medicine emphasized that patient safety was a serious problem crossing all health care facilities and that medical errors occurred even in good hospitals with conscientious care providers. A key finding was that medical errors or adverse events were not the fault of individual practitioners but rather a result of the process of health care. The goal of patient safety involves the redesign of patient care processes to make them more resistant to error occurrence (error reduction) and more accommodating to its consequences (error containment), as noted by Patrice L. Splath in 2000.

Although not all medical errors cause injuries, accidental injuries are common in elderly and can be associated with medical errors. The Institute of Medicine states that a medical error is the failure of a planned action (e.g., diagnosis, treatment) to be completed as intended and/or the selection of a wrong treatment plan. Medical errors can contribute to the occurrence of adverse events. An adverse event is an unintentional error that results in negative consequences for the patient such as a drug reaction, a hip fracture, or a pressure ulcer. Studies of adverse events in health care reveal that approximately 70% of all adverse events are preventable. Of the remaining 30% of adverse events, 24% are typically unavoidable and the remaining 6% are viewed as “potentially” preventable, as noted by Lucian Leape in 1994. Regardless of the etiology of the adverse events, associated injuries result in significant cost, including morbidity, mortality, loss of function, and diminished quality of life.

Risk Factors/Hazard Conditions

Patient risk factors are the most obvious contributor to medical errors and accidents, especially in geriatric patients. These risk factors include diminished reserves due to normal aging changes as well as type and severity of illness or disability, medications (changes in pharmacokinetics and pharmacodynamics in older individuals), multiple morbidities, and psychosocial factors (e.g., lack of compliance, depression). Patient risk factors can facilitate or impede safety barriers and have a direct effect on situational risk factors. Understanding the epidemiology related to adverse events in subpopulations is critical for identifying patients at high risk, designing models for predicting adverse events, designing screening tools, and designing primary and secondary prevention strategies. For example, we know from research that the risk of a person falling increases dramatically as the number of risk factors increases, ranging from a probability of .27 for those with no risk factors or one risk factor to .78 for those with four or more risk factors. In a 1996 study by T. V. Nguyen and colleagues, the probability of fractures ranged from 0 for those with no identified predictors to 0.129 for those with all six predictors present. The injury susceptibility in older adults stems from a high prevalence of comorbid diseases (e.g., osteoporosis, neurological problems), increased likelihood of medication side effects, and age-related decline (e.g., slowed reflexes), all of which can make even a relatively mild fall dangerous. Risk factors can also be categorized as nonmodifiable (e.g., age, gender) or modifiable (e.g., deconditioning), allowing the identification of clinical interventions to decrease risk such as review and modification of risky medication regimens, exercise regimens, smoking cessation, weight loss, and environmental interventions. They also can be categorized as intrinsic (related to normal aging changes, functional status, and comorbidities) or extrinsic (outside of the patient; i.e., related to the environment and medication use).

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