Dementia As A Safety Risk Factor

March 29, 2016    |   By: Alex Christgen, BS, CPPS, CPHQ

Healthcare providers know how hard it can be to keep patients with dementia safe.  But what happens when the existence of dementia or its degree are unknown or unappreciated?  The Pennsylvania Patient Safety Authority receives mandated reports from that state’s hospitals on many safety issues.  Recently, they analyzed the role of a dementia diagnosis in those events, and published a report, available here.  The study was initiated by a public complaint that providers had been unresponsive to family statements about the extent of a patient’s impairment.  The standard questions in the ED did not reveal a problem, yet the family insisted that the patient needed additional precautions and help with providing history.  While he could successfully answer “orienting” questions, the patient denied having had surgery, despite having undergone a quadruple bypass.

I have watched my own mother carry on a decent interview and insist that she could walk unaccompanied with a cane or walker, though she hadn’t walked without a gait belt and standby assistance in years.  She would deny hospitalization, though she had two intensive care stays over a recent 12-month period.  We are thankful now when she just says that she can’t remember.

The PPA identified five primary failure modes in more than 3,000 reports gathered over nearly 10 years.  A wide variety of safety outcomes could be affected by these factors:

  • Failure to recognize preexisting dementia;
  • Failure to assess competence and decision-making capacity of patients with dementia;
  • Failure to identify a reliable historian or surrogate decision maker for patients with dementia;
  • Failure to contact a reliable historian or surrogate decision maker when information or consent was required for care; and
  • Failure to communicate the patient’s dementia diagnosis, competence, and decision-making capacity with all members of the healthcare team

The Center for Patient Safety has more than 40,000 events in its database, and is taking steps to dramatically improve its ability to mine those events for these sorts of findings.  There is so much to learn.


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