Older folks in hospitals : the contributing factors and recommendations for incident prevention

Objectives: To identify the most common errors and adverse events and their contributing factors among the older patients admitted to hospital and examine recommendations from an expert review panel for prevention and reduction of the adverse events. Background: Older patients are at an increased risk of errors and adverse events while hospitalized. The increasing evidence suggests that understanding the risks factors that contribute to these errors and adverse events facilitates the education of health professionals and the reduction and preventions of the harm. Method: A retrospective audit of the Incident Information Management System and Root Cause Analysis databases from July 1, 2005, to June 30, 2006, was undertaken in 1 large tertiary metropolitan hospital in New South Wales, Australia. Results: Of the 643 incidents identified, falls (n = 309), medication errors (n = 136), and clinical management (n = 104) were the most common errors among older patients, and the failure of clinicians to follow policies and procedures and poor communication between clinicians contributed to these incidents. Conclusions: Although systems are in place for incident reporting and analysis of the contributing factors, improvement depends upon clinicians taking responsibility for anticipating and moderating risk using previous data to identify system weaknesses and monitoring improvements especially in hospitalized older patients.