Noha Ferrah

Resident-to-resident physical aggression leading to injury in nursing homes: a systematic review

BACKGROUND resident-to-resident aggression (RRA) is an understudied form of elder abuse in nursing homes. OBJECTIVE the purpose of this systematic review was to examine the published research on the frequency, nature, contributing factors and outcomes of RRA in nursing homes. METHODS in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research published in English, French, German, Italian or Spanish between 1st January 1949 and 31st December 2013 describing incidents of RRA in nursing homes. The following information was extracted for analysis: study and population characteristics; main findings (including prevalence, predisposing factors, triggers, nature of incidents, outcomes and interventions). RESULTS eighteen studies were identified, 12 quantitative and 6 qualitative. The frequency of RRA ranged from 1 to 122 incidents, with insufficient information across the studies to calculate prevalence. RRA commonly occurred between exhibitors with higher levels of cognitive awareness and physical functionality and a history of aggressive behaviours, and female targets who were cognitively impaired with a history of behavioural issues including wandering. RRA most commonly took place in the afternoon in communal settings, was often triggered by communication issues and invasion of space, or was unprovoked. Limited information exists on organisational factors contributing to RRA and the outcomes for targets of aggression. CONCLUSIONS we must continue to grow our knowledge base on the nature and circumstances of RRA to prevent harm to an increasing vulnerable population of nursing home residents and ensure a safe working environment for staff.

The forest or the trees: preference for global over local image processing is reversed by prior experience in honeybees

Traditional models of insect vision have assumed that insects are only capable of low-level analysis of local cues and are incapable of global, holistic perception. However, recent studies on honeybee (Apis mellifera) vision have refuted this view by showing that this insect also processes complex visual information by using spatial configurations or relational rules. In the light of these findings, we asked whether bees prioritize global configurations or local cues by setting these two levels of image analysis in competition. We trained individual free-flying honeybees to discriminate hierarchical visual stimuli within a Y-maze and tested bees with novel stimuli in which local and/or global cues were manipulated. We demonstrate that even when local information is accessible, bees prefer global information, thus relying mainly on the objects spatial configuration rather than on elemental, local information. This preference can be reversed if bees are pre-trained to discriminate isolated local cues. In this case, bees prefer the hierarchical stimuli with the local elements previously primed even if they build an incorrect global configuration. Pre-training with local cues induces a generic attentional bias towards any local elements as local information is prioritized in the test, even if the local cues used in the test are different from the pre-trained ones. Our results thus underline the plasticity of visual processing in insects and provide new insights for the comparative analysis of visual recognition in humans and animals.

The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System.

BackgroundMedico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS).MethodsPubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000–2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers.ResultsOf the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders.ConclusionsTo ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.

Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents

Medication errors (MEs) result in preventable harm to nursing home (NH) residents and pose a significant financial burden. Institutionalized older people are particularly vulnerable because of various organizational and individual factors. This systematic review reports the prevalence of MEs leading to hospitalization and death in NH residents and the factors associated with risk of death and hospitalization. A systematic search was conducted of the relevant peer‐reviewed research published between January 1, 2000, and October 1, 2015, in English, French, German, or Spanish examining serious outcomes of MEs in NHs residents. Eleven studies met the inclusion criteria and examined three types of MEs: all MEs (n = 5), transfer‐related MEs (n = 5), and potentially inappropriate medications (PIMs) (n = 1). MEs were common, involving 16–27% of residents in studies examining all types of MEs and 13–31% of residents in studies examining transfer‐related MEs, and 75% of residents were prescribed at least one PIM. That said, serious effects of MEs were surprisingly low and were reported in only a small proportion of errors (0–1% of MEs), with death being rare. Whether MEs resulting in serious outcomes are truly infrequent, or are underreported because of the difficulty in ascertaining them, remains to be elucidated to assist in designing safer systems.

A review of coronial investigations into medication-related deaths in Australian residential aged care

Background: Residential aged care is a complex and challenging clinical setting where medication errors continue to occur despite efforts to improve medication safety. No studies have sought to review and synthesize coronial investigations into medication‐related deaths in Australian residential aged care facilities (RACFs). Objective: To review coronial investigations into medication‐related deaths in Australian RACFs. Methods: A national review of medication‐related deaths between July 2000 and July 2013 reported to Australian Coroners was performed. Data were extracted from the National Coronial Information System and errors categorized according to stages of the medication management cycle. Results: The database search identified thirty coronial investigations into deaths. Single medication classes were implicated in 22 deaths; including opioids (n = 7), antipsychotics (n = 4) and antidepressants (n = 3). Eight deaths resulted from two or more medication classes. Thirteen deaths reported stages of medication errors, including administration (n = 9) and monitoring (n = 4). Coroners made recommendations following three deaths; including education and training on dose administration aids, regulation of personal care workers, and protocol‐based renal function monitoring for residents taking digoxin. Conclusions: Deaths involving high‐risk medications occurred primarily at the stages of administration and monitoring. Few investigations resulted in specific recommendations, however it is unknown whether these were implemented.

Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process:

Objective: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. Method: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. Results: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. Discussion: Mortality in the immediate period following admission may not simply be due to an individual’s health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors.

A greater risk of premature death in residential respite care: a national cohort study

Background the demand for residential respite care for older persons is high yet little is known about the occurrence of harm, including death in this care setting. Objective to compare the prevalence and nature of deaths among residential respite to permanent nursing home residents. Design retrospective cohort study. Setting australian accredited nursing homes between 1 July 2000 and 30 June 2013. Subjects respite and permanent residents of Australian accredited nursing homes, whose deaths were investigated by Australian coroners. Methods prevalence of deaths of nursing home residents were calculated using routinely generated coronial data stored in the National Coronial Information System. Odds ratios (OR) were calculated to examine residency (respite or permanent) by cause of death. Results of the 21,672 residents who died during the study period, 172 (0.8%) were in respite care. The majority of deaths were due to natural causes. A lower proportion occurred in respite (n = 119, 69.2%) than permanent (n = 18,264, 84.9%) residents. Falls-related deaths in respite as a proportion (n = 41, 23.8%) was almost double that in permanent care (n = 2,638, 12.3%). Deaths from other injury-related causes (such as suicide and choking) were significantly more likely in respite residents (OR = 2.0; 95% confidence interval: 1.1-3.6; P = 0.026). Conclusions this is the first national cohort study examining mortality among respite residents. It established that premature, injury-related deaths do occur during respite care. This is the first step towards better understanding and reducing the risk of harm in respite care.

Overview of surgical death investigations: could a dreaded experience be turned into an opportunity?

The prospect of an investigation into the death of a patient often raises apprehension among surgeons, even when there are no allegations of negligence. Although a focus on identifying system failures and prevention is promoted, investigations may be emotionally charged, examine events with the benefit of hindsight, removed from the context of the ‘lived experience’ and judged against the benchmark of an ideal surgeon. This propensity to revert to a model of ‘medical perfectionism’ characterized by unrealistic expectations can result in the development of a culture of blame which can lead to resistance towards active engagement with investigations. The primary purpose of death investigations is to improve care and ensure patient safety, a goal shared with all surgeons. Unfortunately, many surgeons first learn about them when they are in the midst of one. We fear what we do not know, especially if it threatens our personal identity and professional life. Trainees and fellows should be better informed of the purpose and process of various types of death investigations, which may allow a potentially negative experience to be an opportunity to improve the care of their patients. Surgical death investigations can be broadly classified into medical or legal processes. Although examining the same event, each has its own particular perspective with respect to patient safety (Fig. S1, Appendix S1). Mortality audits have an educational rather than disciplinary purpose. They tend to focus on the technical aspects of clinical care, representing an invaluable opportunity for surgeons to reflect on their practice, improve patient safety and reveal system failures. The resulting practical recommendations are disseminated within surgical craft groups under the umbrella of the Royal Australasian College of Surgeons (RACS), which administers such an audit, compulsory for its Fellows. RACS has also developed a guideline for the conduct of local morbidity and mortality audits. There is evidence that these audits reduce mortality, but is uncertain what proportions of recommendations are implemented and whether their impacts are subsequently evaluated. Aggregate data provide a reliable and contemporary representation of the state of surgical care at a national level and of trends in mortality. However, such assessments often do not involve other stakeholders, and thus may lack the breadth of analysis provided by other investigations. Utilizing only a surgical specialist approach may lead to a missed opportunity for cross-disciplinary interventions. In addition, their benefits may be elusive to patients, as reports are not released to the public in a comprehensible form. Hospital internal investigations, despite being confidential, lead to concern among surgeons as they are often seen as being synonymous with misconduct determinations. Nevertheless, the involvement of non-surgical experts and witnesses means that broader system failures are more readily identified. They represent a complementary tool that help ensuring system-wide compliance with healthcare standards and their more open, broader approach tends to maintain surgeons’ credibility with the public. Medical board investigations shift the focus to maintaining public safety through the examination of individual clinical behaviours. These can lead to drastic and long-lasting consequences on employability, reputation and insurance status. In Australia, 30% of complaints to medical boards result in some regulatory action. Yet again, a potentially painful experience may be turned into an enriching one for surgeons with sufficient insight. In addition, surgeons may appeal to administrative tribunals to overturn sanctions, while patients cannot. While medically based, these investigations operate within formal quasi-legal procedures that provide an avenue through which patients are able to engage and express their concern. Unlike civil claims in negligence, where the terms of a settlement may be confidential between the parties, information from medical board investigations is publicly available and can contribute to patient injury prevention, although empirical evidence supporting this is limited. Coronial investigations are legal enquiries examining system failures on a patient’s journey. They involve non-surgical experts who have significant experience in identifying system failures likely to be present in health care that contributed to a death, without focusing solely on the contribution of the surgeon. Such investigations are typically lengthy, to the extent that local policies may have already changed by the time coroners deliver their finding. While coroners do not have the power to enforce implementation of their recommendations, nor to impose sanctions or determine civil liability, healthcare organizations may be required to respond to published recommendations. Civil litigation and criminal prosecution is a further legal avenue with emphasis on surgeons’ actions and responsibilities. It is a private dispute between the plaintiff and the defendant, focused on compensation. As a result, it has far less potential for improving patient safety. Many cases are unrepresentative of broader system concerns, and judgements are often shrouded in confidentiality clauses that restrict learning. Rarely, gross medical negligence leads to a criminal prosecution. Although the role of criminal courts is primarily to identify and punish criminal wrongdoing, proceedings may identify system failure and foster confidence in the overall healthcare system. Anxiety induced by these investigations could be reduced by enhancing understanding of their nature and purpose. This could be