Key Findings: Safety Incident Reporting in Care Homes

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In this blog, we are sharing the key findings on safety incident reporting in care homes in a paper published by the Journal of Advanced Nursing. The study was a systematic review on the types of safety incidents, the processes and systems used for safety incident reporting in the care home sector.

Introduction

Safety incident reporting in care home settings, including residential and nursing homes (sometimes referred to as long-term care facilities), is in its relative infancy. Within the care home settings, there are differences depending on the funding sources, regulatory systems and the type of care provided. This contributes to the lack of standardization on safety incident reporting.

The review aimed to improve our understanding of safety incident reporting in care homes, with two specific objectives:

  1. Identify the safety incident reporting systems and processes used within care homes to capture reports of safety incidents.

  2. Identify the types and characteristics of safety incidents captured by safety incident reporting systems in care homes.

The review was conducted in line with the PRISMA 2020 guidelines, involving 106 studies that met the eligibility criteria. All the studies and data analyzed were from developed countries. This suggests a gap in safety practices in care homes between high-income and lower and middle-income countries.

Key findings

  • The review found there was no standard reporting system used in care homes, though incident reporting systems and processes do share many common features, suggesting that there is an opportunity to develop more standardized systems to improve cross-organizational learning.

 

  • Electronic incident reporting systems were the most common amongst studies included in this review. However, it is likely that reporting bias contributed to this finding, as paper-based incident reporting systems can produce inconsistent data and less accurate analyses, and therefore less likely to be studied.

 

  • Core information that was captured related to the residents, incident details, what caused the incident, the severity and injuries sustained, and the actions taken to prevent the incident from reoccurring, though the data captured via incident reporting systems were heterogeneous.
Fig. 1 Summary of incident report data captured by incident reporting systems in care homes.
  • The most frequently reported incident categories were resident behavior, falls, medication issues, clinical process/procedure, and documentation, which broadly reflects previous evidence. The comparison with existing literature highlights how safety incident reporting, when data are synthesized, can be a useful tool for identifying the types of safety incidents that occur in care homes.

 

  • Notably, only one study examined had safety incident on admission, and one other study had incident related to transfer of care. Since both admissions and transfers are known to be high in risk, this suggests that further safety awareness in these areas may be required.

 

  • Nurses were responsible for incident reporting far more than any other profession or role, reflecting the prominent role that nurses take in safety work. Only one study showed another patient or resident reported an incident. This suggests a lack of awareness among other workers and residents on the importance of incident reporting.

 

  • The most reported action to reduce risk was to improve safety culture. Safety culture in care homes is still relatively poorly understood, and the large variation in care home contexts and approaches to reporting safety incidents suggests that a single measure of safety culture for care homes would be difficult to achieve.

 

  • Overwhelmingly, cognition was the most reported patient contributing factor, reflecting the population group being studied. This finding provides support for the development of safety interventions that target patient cognition, such as technology to monitor patients with dementia.

 

  • The next highest contributing factor was patient behavior, followed by organizational issues such as protocols, policies and guidelines and workload challenges. Staff contributing factors included performance and communication, reaffirming the importance of training to improve competencies and teamwork.

Implications for policy and practice

Nurses play a crucial role in care home safety incident reporting, in keeping with their overall focus on safety work and safety leadership within care home settings. In some countries and settings, this will be reinforced by statutory and regulatory obligations. However, not all care homes, particularly residential homes, will have access to regular nursing care. Where this is the case, the responsibility for incident reporting may fall onto others who should receive adequate training and support for reporting, managing, and learning from safety incidents.


The review findings highlight a need to ensure standard reporting practice across the care home sector, including the types of data captured in safety incident reports. Whilst incident reporting data is unreliable for epidemiological purposes, efforts should still be made to improve its reliability to better inform practice, policy, and research within the care home sector.


Additionally, there should be standard practice for using incident reports to improve and inform resident care, including learning from incidents, which includes providing feedback to the staff involved, but also the resident and family of the person.

Conclusion

This systematic review has identified a complex picture of incident reporting in care homes, with the evidence base notably limited to high-income countries, highlighting a significant knowledge gap. Several types of incidents contribute heavily to the literature, including falls, medication issues, patient behavior, documentation and more general clinical processes and procedures. The findings emphasize the vital role of nursing staff in reporting safety incidents and the lack of standardized reporting systems and processes.


Cognition was the most reported patient contributing factor, followed by patient behavior, organizational issues such as protocols, policies and guidelines and workload challenges. The development of safety interventions that target patient cognition, such as technology to monitor patients with dementia, will be most useful.

 

Source: Adopted from “Systematic review of types of safety incidents and the processes and systems used for safety incident reporting in care homes” by Scott, J., Sykes, K. etc (2024). Journal of Advanced Nursing, 00, 1–47.

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