Dementia patients linked with near-misses


Medical staff being unaware of a patient’s dementia diagnosis has led to a worrying number of near-miss patient safety events, according to a Pennsylvania Patient Safety Advisory article released this month.

Pennsylvania healthcare facilities reported 3,710 events from January 2005 through December 2014 involving patients with dementia or potentially unrecognized dementia. Falls were the most frequently reported event type (46.1 percent), followed by impaired skin integrity (bed sores or other wounds) (25.8 percent). The majority of events were reported as incidents without harm to patients (86.1 percent).

“Of the events analyzed, there were 63 events similar to the one reported by the family member of the patient with dementia,” said Michelle Feil, analyst of the Pennsylvania Patient Safety Authority. “Through the analysis of these similar events, common mistakes were made by healthcare providers.”

The five common mistakes on the part of the healthcare provider that occurred throughout the similar events include: failure to recognize preexisting dementia; failure to assess the ability of patients with dementia to make decisions; failure to identify a person who could provide correct information or make decisions for dementia patients; failure to contact a caregiver or decision-maker when information or consent was needed; and failure to communicate the patient’s dementia diagnosis and decision-making ability to all members of the healthcare team.

Feil said risk reduction strategies are provided in the advisory for healthcare providers to target the common mistakes.

“Screening for dementia, assessing a patient’s ability to answer questions, identifying and communicating with surrogate decision-makers and making sure all hospital staff are aware of the dementia patient’s diagnosis, are all strategies that reduce the risk of a poor outcome for patients with dementia when using the healthcare system,” Feil said.

“It's also important for family members of dementia patients to educate themselves about dementia, including signs and symptoms and problems commonly faced in the healthcare setting.”

Dementia, Pennsylvania Patient Safety Advisory, Healthcare, Michelle Feil, US