Care home safety incidents and safeguarding reports relating to hospital to care home transitions: A retrospective content analysis (October 2024)

Summary

The purpose of this study was to look at reported patient safety events at the interface between hospital and care home including what active failings and latent conditions were present and how reporting helped learning.

Two care home organisations, one in the North East and one in the South West of England, participated in the study. Reports relating to a transition and where a patient safety event had occurred were sought during the Covid-19 virus prepandemic and intrapandemic periods. All reports were screened for eligibility and analysed using content analysis.

The findings highlight potentially high levels of underreporting. The most common safety incidents reported were pressure damage, medication errors, and premature discharge. Many active failings causing numerous staff actions were identified emphasizing the cost to patients and services. Additionally, latent conditions (failings) were not emphasized; similarly, evidence of learning from safety incidents was not addressed.