Family members advocate for improved identification of patients with dementia in the acute care setting
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Feil, Michelle, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, March 2016
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Alzheimer Disease -- diagnosis Cognition Disorders -- diagnosis Decision Making Dementia -- diagnosis Informed Consent Medical Errors -- prevention & control Mental Competency Cognitive Dysfunction -- diagnosis Color Communication Family Hospitals Patient Advocacy Patient Identification Systems -- methods Proxy Risk Management Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- A family member of a patient with dementia contacted the Pennsylvania Patient Safety Authority and described several "near miss" patient safety events in which hospital staff obtained inaccurate information from the patient, unaware of the patient's dementia diagnosis. Healthcare facilities reported 3,710 events through the Pennsylvania Patient Safety Reporting System between January 2005 and December 2014 involving patients with dementia or potentially unrecognized dementia. Analysts reviewing these reports found 63 similar events in which hospital staff obtained inaccurate information or consent from these patients. Five failure modes were identified: (1) failure to recognize preexisting dementia; (2) failure to assess competence and decision-making capacity of patients with dementia; (3) failure to identify a reliable historian or surrogate decision maker for patients with dementia; (4) failure to contact a reliable historian or surrogate decision maker when information or consent was required for care; and (5) failure to communicate the patient's dementia diagnosis, competence, and decision-making capacity with all members of the healthcare team. Risk reduction strategies targeting these failure modes include screening for dementia, assessing capacity, identifying and communicating with surrogate decision makers, and standardizing communication of a patient's dementia diagnosis with all hospital staff.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (10 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101679100 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101679100