Reducing preventable harm to residents in aged care: A systems approach

Area of Science:

• Gerontology
• Healthcare Quality and Safety
• Aged Care Management

Background:

• Residents in Australian aged care facilities are vulnerable to serious, preventable harm from adverse events (AEs).
• Inadequate responses to AEs by facilities can exacerbate distress for residents and their families.
• Facilities have a legal and ethical obligation to manage AEs effectively.

Purpose of the Study:

• To highlight the critical need for robust responses to adverse events in aged care.
• To emphasize the importance of a supportive culture for reporting and managing AEs.
• To propose enhanced governance functions for the Aged Care Quality and Safety Commission.

Main Methods:

• Analysis of current practices in Australian aged care facilities regarding adverse event management.
• Review of the obligations and roles of aged care facilities and regulatory bodies.
• Identification of systemic improvements for reporting, investigation, and learning from AEs.

Main Results:

• Aged care facilities must foster a culture of open reporting and provide adequate resources for AE management.
• Effective response and investigation of AEs are essential to prevent recurrence and reduce resident/family distress.
• Current governance could be enhanced through national sharing of lessons learned and quality assurance of investigations.

Conclusions:

• Strengthening aged care facility responses to adverse events is paramount for resident safety.
• The Aged Care Quality and Safety Commission should assume greater national oversight, including quality assurance and system-wide investigations.
• A systemic approach is required to ensure continuous improvement in aged care safety and quality.