and transition between services, allowing congruent treatment plans and optimal outcomes. Transitions of care, particularly the interface between primary and secondary care in acute hospitalization (at both admission and discharge), can be particularly problematic. This is a critical phase in the healthcare journey of older people, and there is a risk of problems related to health and/or care immediately after transition. Twenty percent of older people face adverse event in the transition phase, 60% of which are preventable.56
The goal of care for a frail person in the hospital is not just to treat their acute illness but also to promote maximum functional recovery and independence – in other words, to prevent functional decline. Achieving this goal requires systems to be set up in the hospital so that patients who are frail and at risk of functional decline can be recognized and treated early to prevent adverse outcomes. However, this does not always occur, particularly when older people are admitted (justly) to areas or departments where systems are geared more toward the care of younger, fitter people (such as surgery).
Several other systems factors may contribute to adverse events in the care of older people in the hospital. These can give rise to poor communication: for example, inadequate procedures for handover for medical and nursing staff, either between themselves when shifts change or between disciplines when decisions are made. Systems factors may also limit good communication: for example, time constraints and pressures due to the volume of work may not allow healthcare professionals to take the time required to assess an older person thoroughly, decide on a good management plan, initiate it, and communicate all of this effectively to the patient, their relatives, and other staff caring for them. This means even if an individual has good communication and clinical reasoning skills, the system does not always allow them to be realized to their maximum potential in optimizing patient care.
Improving patient safety for older people
Improving the safety of a clinical system requires action at many different levels, combining a focus on generic issues with attention to specific clinical problems. In this section, we first briefly address three issues that are relevant to all healthcare sectors but particularly critical in the care of older people: the education and training of practitioners, improving systems of care, and the potential of design and technology to enhance safety. We then consider how specific clinical issues can be tackled, addressing interventions for geriatric syndromes, hospital‐acquired infections, and medication safety. A systematic review by Zegers, et al.57 showed that certain interventions were effective. The relevant effective interventions in older people were multicomponent interventions for delirium prevention, medications reviews by pharmacists, and multidisciplinary measures to prevent falls and infections.
Education and skills for individual practitioners
Healthcare professionals caring for older people need to be trained in the clinical reasoning and communication skills necessary to ensure safe and high‐quality care in this challenging group of patients. These skills are essential for accurate and thorough initial assessment, and a lack of such skills may lead to diagnostic errors and subsequent mismanagement in addition to poor overall quality of care. Explicit training to develop these difficult skills can be wanting, and this ability is often expected to develop with experience. Box 11.3 lists some of the individual skills or behaviours that geriatricians use to maximize patient safety in older people.
1 Early detection and prevention, where possible, of frailty and geriatric syndromes
2 Medication review and reconciliation at every opportunity
3 Ensuring that a full collateral history is taken at every available opportunity
4 Maximizing communication at times of transition of care
5 Involving patients in their care as much as possible
6 Working with management to try to improve organisational culture toward older people
7 Ensuring that basic compassionate care is carried out
8 Supporting effective multidisciplinary teams that share goals and information as much as possible
9 Inspiring interest in the care of older people amongst juniors and other colleagues
10 Being aware of cognitive biases in decision‐making and the use of strategies to overcome them
The same communication and clinical reasoning skills required for geriatric assessment are also required to detect and manage adverse events in older people once they have occurred during a hospital admission. Successful care of older people requires staff to make complex decisions about medical and non‐medical matters with the involvement of the whole multidisciplinary team and with the aim of meeting patients’ best interests. In the hospital, this applies to decisions regarding both the inpatient care that elderly patients receive and the complex planning that is often required to maximize their safety on discharge from the hospital. Several educational strategies have been suggested to improve clinical reasoning,23 such as the introduction of training in formal critical thinking, teaching with the use of clinical examples of cognitive biases, encouraging consideration of diagnostic alternatives, developing mental rehearsal for practical skills using simulations, and using cognitive aids such as guidelines, algorithms, or handheld computer devices.
Medical and nursing curricula should teach the recognition of frail and complex patients so that interventions for frailty and to prevent the occurrence of the geriatric syndromes can be implemented early. Undergraduate medical education should be designed to allow future practitioners to understand the physiological differences associated with age, informing safe prescribing for older people. Increasing attention is being paid to teaching communication skills – these need to be designed with the specific ability required of all healthcare professionals to communicate effectively with older people, such as those with cognitive or sensory impairment.
Keeping patients safe, particularly those with complex and fluctuating conditions, also requires anticipation, awareness of hazards, preparedness, resilience, and flexibility: the qualities that those studying high‐reliability organizations have sought to capture and articulate. To try to instil these qualities into the next generation of clinicians, patient safety is being incorporated explicitly into both undergraduate and postgraduate training. To aid this endeavour, there has been some work to identify the desirable knowledge, skills, behaviours, and attitudes of a safe healthcare practitioner. In surgery and anaesthesia, much work has been done to identify and enhance non‐technical skills–including communication, stress management, teamwork, decision‐making, and leadership58 – that promote patient safety. Similar skills are, of course, crucial across all specialities, particularly in the care of older people.
Design (human factors and ergonomics) and technology
Increasingly, design and technology are being used to great effect to improve patient safety as healthcare learns from the principles of human factors and ergonomics that are well‐engrained in other safety‐critical industries. These disciplines are concerned with the interaction between humans and the systems in which they work, including perception, cognition, human performance, interaction with technology, teamwork, and organizational behaviour. Design of hospital equipment used to be carried out by people at a relative distance from end users, with feedback occurring only at a late stage or when accidents occurred. Now there tends to be a much more integrated approach, with a substantial and growing literature around evidence‐based design. This has led to numerous practical benefits, such as the redesign of labelling and packaging of medications and anaesthetic and emergency equipment, and in designing hospital environments to reduce the incidence of hospital‐acquired infections.1
The same principles