Family Member of Dementia Patient Prompts Patient Safety Advisory

Data and analysis point to communication gaps between healthcare providers and families of dementia patients

Mar 15, 2016, 08:00 ET from Pennsylvania Patient Safety Authority

HARRISBURG, Pa., March 15, 2016 /PRNewswire-USNewswire/ -- A family member of a patient with dementia prompted the March Pennsylvania Patient Safety Advisory article released today along with consumer tips to make healthcare providers and dementia patient families more aware of problems that can occur when a patient with dementia uses the healthcare system.

A family member of a patient with dementia contacted the Pennsylvania Patient Safety Authority and described several "near miss" (events that did not harm the patient) patient safety events in which hospital staff obtained incorrect information from the patient, unaware of the patient's dementia diagnosis.

Pennsylvania healthcare facilities reported 3,710 events to the Authority from January 2005 through December 2014 involving patients with dementia or potentially unrecognized dementia. Falls were the most frequently reported event type (n=1,710, 46.1%), followed by impaired skin integrity (bed sores or other wounds) (n=958, 25.8%). The majority of events were reported as Incidents without harm to patients (n=3.194, 86.1%).

"Of the events analyzed, there were sixty-three events similar to the one reported by the family member of the patient with dementia," Michelle Feil, MSN, RN, CPPS, analyst of the Pennsylvania Patient Safety Authority said. "Through the analysis of these similar events, common mistakes were made by healthcare providers."

The five common mistakes on the part of the healthcare provider that occurred throughout these similar events include: 1) failure to recognize preexisting dementia; 2) failure to assess the ability of patients with dementia to make decisions; 3) failure to identify a person who could provide correct information or make decisions for dementia patients; 4) failure to contact a caregiver or decision maker when information or consent was needed; and 5) failure to communicate the patient's dementia diagnosis, and decision-making ability with all members of the healthcare team.

Feil said risk reduction strategies are provided in the Advisory for healthcare providers to target the common mistakes.

"Screening for dementia, assessing a patient's ability to answer questions, identifying and communicating with surrogate decision makers and making sure all hospital staff are aware of the dementia patient's diagnosis, are all strategies that reduce the risk of a poor outcome for patients with dementia when using the healthcare system," Feil said. "It's also important for family members of dementia patients to educate themselves about dementia, including signs and symptoms and problems commonly faced in the healthcare setting."

"The Authority has developed consumer tips to help family members recognize signs and symptoms of dementia and Alzheimer disease, and suggests questions to ask and information to have on hand to help the healthcare provider serve your loved one with dementia better," Feil added.  

For more information about dementia and the strategies to provide the best possible outcome for dementia patients, go to the March Pennsylvania Patient Safety Advisory article, "Family Members Advocate for Improved Identification of Patients with Dementia in the Acute Care Setting," at For the consumer tips "Dementia Patients and the Healthcare System: What You Should Know" go to the Authority's website, click on Patients and Consumers.

Other highlights of the 2016 March Advisory include the following:

  • Missed Respiratory Therapy Treatments: Underlying Causes and Management Strategies: For patients who suffer from respiratory ailments, a missed treatment may worsen an existing condition and contribute to the patient requiring a higher level of care. Events submitted to the Authority identified 8,745 missed respiratory treatments reported over a five-year period; 22.8% of the event reports did not provide a reason. Respiratory therapists who responded to a survey indicated treatments were missed due to patient unavailability because of other therapies or tests; patient refused treatments; or the respiratory therapist was unavailable because of an emergency situation or increased workload. Strategies to address missed respiratory treatments are included in this article.  
  • Medication Errors Involving Healthcare Students: Students acquire vital clinical experience while participating in patient care, but they can become involved in medication errors. Analysts reviewed medication-error events mentioning students submitted to the Authority. Of the 711 events identified, 87.3% (n=621) reached the patient. Analysts also found students caught or discovered the error in 16.2% (n=115) of reports. Professional organizations, healthcare facilities, and professional schools can help reduce the risk of student-involved errors by implementing key strategies provided in this article.
  • A Conceptual Framework for Improving Isolation Awareness in Pennsylvania Acute Care Hospitals: The relationship between achievement, avoidance of failure, and personal risk in terms of worker compliance with isolation and related procedures is examined. Situational and isolation precaution awareness are explored in this article to describe healthcare-worker behavior in an environment where isolation precautions are indicated.
  • Authority Recognized Healthcare Providers Committed to Patient Safety: The Authority's annual I Am Patient Safety poster contest promotes individuals and groups within Pennsylvania's healthcare facilities who have demonstrated an exceptional commitment to patient safety. This year with over 170 nominations, 21 healthcare workers from 12 different healthcare facilities were recognized. To view the 2016 recognized winners of the poster contest, go to and click on brochures.

Other Advisory features include: "Decline in Serious Events and Wrong Drug Reports Involving Opioids in Pennsylvania Facilities," "The Forgotten Tourniquet—An Update" and "More than Complicated, Healthcare Delivery is Complex, Adaptive and Evolving."

The Authority also has available through its website a YouTube video of how to properly remove a tourniquet from a patient and a podcast interview about "Distractions in the Operating Room" from the June 2014 Advisory article.

To view the complete 2016 March Pennsylvania Patient Safety Advisory, go to

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SOURCE Pennsylvania Patient Safety Authority