Improving Patient Safety in Long-Term Care Facilities


Since the Institute of Medicine issued its landmark report, To Err is Human: Building a Safer Health System,1 in 1999, there have been tremendous strides toward improving patient safety and reducing medical errors in health care facilities. Substantial improvements have taken place in hospitals, in particular, yet progress on this front has been spotty in nursing homes and other longterm care facilities. Some of the reasons for this include differences in the patient populations served, the dual role of nursing homes as both health care and residential facilities, and staffing challenges that include high levels of turnover, wide variation in education levels, and varied cultural and language backgrounds.

Training nursing home staff—particularly nursing staff—to be on the lookout for changes in a nursing home resident's condition and to effectively communicate those changes is one tool nursing home administrators can employ to improve patient safety, create a more resident-centered environment, and reduce the number of falls and fall-related injuries.

Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety. Such changes may represent a patient safety problem, and they can be a signal that the resident is at increased risk for falling and other complications. All staff members share responsibility for noticing and reporting both physical changes (e.g., difficulty with balance, increased frailty or weakness, changes in urination and/or bowel patterns) and nonphysical changes (e.g., increased or decreased appetite, signs of withdrawal, confusion, or agitation) in a resident's condition.

These educational materials are intended for use in training front-line personnel in nursing homes and other long-term care facilities. The materials were developed by RAND Corporation, with support from the Agency for Healthcare Research and Quality (AHRQ). These training materials are organized into three modules:

This Instructor Guide presents training materials for all three modules, including suggested slides and pre- and post-tests to gauge the students' knowledge level before and after training. There is no need for instructors to flip from one section to another when using these modules, as some of the basic information (e.g., information on teaching methods) is repeated in each module, to ensure that each module is a complete teaching guide. Separate student workbooks are available for each module. Facilities can use the modules sequentially or independently, and the content can be tailored to fit the needs of individual facilities.

Institute of Medicine (IOM). 2000. To Err Is Human: Building a Safer Health System. L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, eds. Washington, D.C: National Academy Press.

Page last reviewed October 2014
Page originally created June 2012
Internet Citation: Introduction. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.
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