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

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

Frontiers of Nursing
Volume 10 (2023): Issue 4 (December 2023)
By: Dominika Kohanová,  Martina Lepiešová,  Daniela Bartoníčková,  Pavol Faťun and  Katarína Žiaková  
Open Access
|Dec 2023

Figures & Tables

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, countryStudy designSampleData collectionData analysisFacility type
Abusalem et al.28, USAQuantitative, crosssectionalN = 252 direct care workersQuestionnaireDescriptive and inferential statisticsNon-specified
Andersson et al.29, SwedenQuantitative, retrospectiveN = 173 reportsAEs reportsContent analysis, descriptive statisticsNursing home
Aranda-Gallardo et al.30, SpainQuantitative, prospectiveN = 647 residentsQuestionnaireDescriptive and inferential statisticsNursing home
Boockvar et al.31, USAQuantitativeN = 122 residentsResidents’ documentationDescriptive and inferential statisticsNursing home
Crespin et al.32, USAQuantitative, cross-sectionalN = 15 037 reportsAEs reportsDescriptive and inferential statisticsNursing home
Daneman et al.33, CanadaQuantitative, cohortN = 110 656 residentsAEs reportsDescriptive and inferential statisticsNursing home
Djikstra et al.34, NetherlandQuantitative, crosssectionalN = 13 633 residentsQuestionnaireDescriptive and inferential statisticsNursing home
Doupe et al.35, CanadaQuantitative, cohortN = 22 846 residentsAdministrative dataDescriptive and inferential statisticsNursing home
Gerety et al.36, USAQuantitative, retrospectiveN = 175 residentsResidents’ documentationDescriptive and inferential statisticsNursing home
Glette et al.37, NorwayQualitative, comparativeN = 17 nurses and nurse managersSemi-structured interviewsContent analysisNursing home
Gurwitz et al.38, USAQuantitative, retrospectiveN = 490 residentsResidents’ documentationDescriptive and inferential statisticsNursing home
Halligan et al.39, CanadaMixed methodN = 26 direct care workersQuestionnaire, semistructured interviewsDescriptive statistics; content analysisNon-specified
Herrmann et al.40, CanadaQuantitativeN = 24 residentsQuestionnaireDescriptive and inferential statisticsNon-specified
Hughes et al.41, USAQuantitative, retrospectiveN = 8267 residentsQuestionnaireDescriptive and inferential statisticsNursing home
Kapoor et al.42, USAQuantitative, prospectiveN = 555 residentsResidents’ documentationDescriptive and inferential statisticsNon-specified
Kapoor et al.43, USAQuantitative, prospectiveN = 555 residentsResidents’ documentationDescriptive and inferential statisticsNursing home
Lannering et al.44, SwedenQuantitative, longitudinalN = 429 residentsQuestionnaireDescriptive and inferential statisticsNursing home
Lexow et al.45, GermanyQuantitative, crosssectionalN = 104 residentsInterviews, residents’ documentation, medication analysisDescriptive and inferential statisticsNon-specified
Lindblad et al.46, SwedenQuantitative, retrospectiveN = 518 recordsResidents’ documentationDescriptive and inferential statisticsNursing home
Lindblad et al.47, SwedenQuantitative, retrospectiveN = 600 recordsResidents’ documentationDescriptive and inferential statisticsNursing home
Lombardo et al.48, ItalyQuantitativeN = 1356 residentsQuestionnaireDescriptive and inferential statisticsNursing home
McDonald et al.49, USAQuantitativeN = 50 residentsResidents’ documentationDescriptive and inferential statisticsNursing home
Niznik et al.50, USAQuantitative, retrospectiveN = 37,106 residentsResidents’ documentationDescriptive and inferential statisticsNursing home
Oliveria et al.51, USAQuantitative, retrospectiveN = 7728 residentsQuestionnaireDescriptive and inferential statisticsNursing home
Prang and Jelsness-Jorgensen52, NorwayQualitativeN = 13 nursesSemi-structured interviewsThematic analysisNursing home
Quach et al.53, USAQuantitative, crosssectionalN = 56 nursesQuestionnaireDescriptive and inferential statisticsNursing home, community center
Resnik and Galik54, USASecondary analysisN = 199 residentsQuestionnaireDescriptive and inferential statisticsNursing home, residential care
Shmueli et al.55, IsraelQuantitative, descriptiveN = 1364 reportsAEs reportsDescriptive and inferential statisticsNon-specified
Trinks et al.56, SwedenQuantitative, retrospectiveN = 40,224 residentsAEs reportsDescriptive and inferential statisticsNursing home, hospital
Van Gaal et al.57, NetherlandQuantitative, prospectiveN = 687 patientsN = 241 residentsResidents’ documentationDescriptive and inferential statisticsNursing home, hospital
Wagner et al.58, USAQuantitative, crosssectionalN = 289 nursesQuestionnaireDescriptive and inferential statistics; content analysisNon-specified
Wagner et al.59, USAQuantitativeN = 399 managers of nursing homesQuestionnaireDescriptive and inferential statisticsNursing home
Wagner et al.60, USAQuantitativeN = 32 states; healthcare departmentsQuestionnaireDescriptive and inferential statisticsNursing home
Wang et al.61, AustraliaQuantitative, casecontrolN = 332 casesN = 332 controlled casesResidents’ documentationDescriptive and inferential statisticsNon-specified
Yu and Perng62, Taiwan, ChinaQuantitative, crosssectionalN = 213 nurse aidsQuestionnaireDescriptive and inferential statisticsNon-specified

AEs impacting physical functioning in LTC facilities_

AEs impacting physical functioningExamples of references
FallsFalls with Injury; Falls while walking; Falls from bed; Witnessed falls; Resident found on the floorAbusalem 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 specifiedAbusalem 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 medicationAndersson 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 residentsAbusalem 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 oedemaBoockvar 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; InsomniaBoockvar 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; PruritusHerrmann 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; PurpuraGurwitz et al.38; Kapoor et al.42; Lexow et al.45; Oliveria et al.51
Respiratory problemsRespiratory failureKapoor 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; DeathDaneman 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 functioningExamples of references
AgitationGerety 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 extremityBoockvar et al.31; Lexow et al.45; Lindblad et al.46; Lindblad et al.47; Oliveria et al.51
Change in mental statusLindblad et al.46; Lindblad et al.47; Lombardo et al.48; Lexow et al.45
HospitalizationUnplanned visit of emergencyGlette 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 behaviourLindblad et al.46; Lexow et al.45; Lombardo et al.48
Errors in communication about residentsLindblad et al.46; Lindblad et al.47; Wagner et al.58
DeliriumKapoor et al.42; Lombardo et al.48; Oliveria et al.51
AnxietyLexow et al.45; Lindblad et al.46; Oliveria et al.51
Suicidal behaviourAndersson et al.29; Wagner et al.60
ViolenceResident-to-resident; Resident-to-staff; Staff-to-residentShmueli et al.55; Wagner et al.60
HallucinationsGerety et al.36; Lexow et al.45
LethargyBoockvar et al.31; Lexow et al.45
Self-injuryShmueli et al.55
Abuse (physical, sexual)Wagner et al.60
Personality changeLexow et al.45
Delays in diagnosis or treatmentKapoor et al.42
Escape of residentYu and Perng62
DepressionLexow et al.45
SuicideWagner et al.60

Resources and methods of collecting the data in analyzed studies_

Resources and methodsExamples of references
Reporting systems
Centers for Medicare and Medicaid ServicesAbusalem et al.28; McDonald et al.49; Niznik et al.50
Health and Social Care InspectorateAndersson et al.29
Medication Error Quality Initiative - Individual Error SystemDaneman et al. 33
Veterans’ Health Administration Office of Reporting, Analytics, Performance, Improvement & DeploymentQuach et al.53
Computerized AE Management SystemShmueli et al.55
the Taiwan Patient Safety Reporting SystemYu and Perng62
Minimum Data SetHughes et al.41; Oliveria et al.51
Instruments
The Dutch National Prevalence Survey of Care ProblemsDjikstra et al.34
The Modified Stanford Patient Safety Culture Survey InstrumentHalligan et al.39
Risk assessment toolsLindblad et al.46; Van Gaal et al.57
Trigger toolLindblad et al.46; Lindblad et al.47
National Survey on AEsLombardo et al.48
Senior Alert,56Trinks et al.56
The Communicating about Nursing Error SurveyWagner et al.58
The Survey on AEs,59Wagner et al.59
The State Incident Reporting Policies and Practices.60Wagner et al.60
Other methods
Residents’ recordsBoockvar 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 toolsHerrmann et al.40
InterviewsGlette et al.37; Lexow et al.45; Prang and Jelsness-Jorgensen52
Verification of the record by caregiver and residents themselvesAranda-Gallardo et al.30
Population-based administrative databasesDaneman et al.33; Doupe et al.35
Cumulative count of AEsResnick and Galik54

The search process in scientific databases PubMed, Scopus, and ProQuest_

Search wordsHits
(“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
Total1057
DOI: https://doi.org/10.2478/fon-2023-0043 | Journal eISSN: 2544-8994 | Journal ISSN: 2097-5368
Journal RSS Feed
Language: English
Page range: 399 - 412
Submitted on: Jan 28, 2023
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Accepted on: Mar 21, 2023
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Published on: Dec 18, 2023
Published by: Shanxi Medical Periodical Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
adverse event,
facility,
factors,
long-term care,
healthcare workers
Related subjects:
Medicine,
Assistive professions, nursing

© 2023 Dominika Kohanová, Martina Lepiešová, Daniela Bartoníčková, Pavol Faťun, Katarína Žiaková, published by Shanxi Medical Periodical Press
This work is licensed under the Creative Commons Attribution 4.0 License.

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