A Multihospital Analysis of Clinician-Reported Safety Events in People Living with Dementia: Contributing Factors and System Recommendations.

Background: People living with dementia (PLWD) are hospitalized at higher rates than those without dementia and are particularly vulnerable to safety events in the hospital. This study aimed to characterize the scope of clinician-reported safety events in PLWD, identify contributing factors from the perspective of reporting clinicians, and categorize clinician recommendations for system improvement.

Methods: The authors analyzed safety events reported by clinicians between January 2018 and July 2023 through a voluntary reporting system at a 10-hospital health system in the mid-Atlantic region, representing a broad spectrum of hospitals and patient populations. A total of 1,287 clinician-reported safety events in PLWD were identified using a keyword search. Two researchers coded the event reports using validated taxonomies to classify contributing factors and clinician recommendations for improvement.

Results: The most common clinician-reported safety events among PLWD were skin/tissue injuries (59.4%), falls (17.2%), and safety/security issues (6.9%). The most frequently cited contributing factors were situational factors (70.0%) and active failures (11.2%). Most clinician reports (65.6%) did not include any recommendation for improvement; 30.0% included person-based recommendations, and only 4.4% included system-based recommendations.

Conclusion: Health systems should prioritize the prevention of pressure injuries and falls-two of the most common and preventable safety events. Effective interventions should integrate both person-based (for example, staff training, patient/family education) and system-based (for example, policies, protocols) strategies to improve safety for PLWD in the hospital.