Patient Safety Culture: A Review of the Nursing Home Literature and Recommendations for Practice.

Patient safety culture (PSC) is a critical factor in creating high-reliability health-care organizations. Most PSC research studies to date have been conducted in acute care settings; however, nursing home studies have recently begun to appear in the literature. Nursing homes differ from hospitals in a number of ways, including the population they serve, the medical model of care, and having the vast majority of direct care provided by non-licensed certified nursing assistants. Research has shown that nursing home PSC differs in important ways from PSC in acute care institutions. Recent PSC studies conducted in nursing homes and related quality and safety research can guide recommendations for nursing homes wishing to evaluate their own PSC. Relationships between PSC measurement, quality improvement, and workforce issues are potentially important and may influence clinical outcomes.

Rationales that providers and family members cited for the use of antipsychotic medications in nursing home residents with dementia.

OBJECTIVES: To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs). DESIGN: Qualitative, descriptive study. SETTING: Twenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions. PARTICIPANTS: Individuals diagnosed with dementia who received an antipsychotic medication. MEASUREMENTS: Data were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded reasons for antipsychotic prescribing were summarized across all sources. RESULTS: Major categories of reasons for use of antipsychotic medications in the 204 NH residents in the study sample were behavioral (n = 171), psychiatric (n = 159), emotional states (n = 105), and cognitive diagnoses or symptoms (n = 114). The most common behavioral reasons identified were verbal (n = 91) and physical (n = 85) aggression. For the psychiatric category, psychosis (n = 95) was most frequently described. Anger (n = 93) and sadness (n = 20) were the most common emotional states cited. CONCLUSION: The rationale for use of antipsychotic drug therapy frequently relates to a wide variety of indications for which these drugs are not approved and for which evidence of efficacy is lacking. These findings have implications for clinical practice and policy.

Certified nursing assistants' perceptions of nursing home patient safety culture: is there a relationship to clinical outcomes?

OBJECTIVES: The main objective of this study was to examine whether certified nursing assistants' (CNAs') perceptions of patient safety culture (PSC) were correlated with clinical outcomes (rates of falls, pressure ulcers, and daily restraint use) in a random sample of nursing homes. An additional objective was to describe facility-level and CNA-level characteristics that were associated with CNA PSC scores. DESIGN: We conducted a secondary data analysis using data that adapted the Hospital Survey of Patient Safety Culture (HSOPSC) for nursing homes. The HSOPSC data were merged with data from the Minimum Data Set (MDS), Online Survey Certification and Reporting (OSCAR) system, and Area Resource File (ARF). PARTICIPANTS AND SETTING: CNAs from a random sample of 72 nursing homes in 5 randomly selected states during the first 2 quarters of 2005. MEASUREMENTS: The relationships between clinical outcomes and CNA PSC scores were evaluated. The relationships between CNA PSC and facility characteristics, such as profit status and bed occupancy, and CNA characteristics such as education and tenure were also assessed. Data were analyzed using Poisson, multinomial logistic, and linear regression, and generalized estimating equations (GEE); descriptive statistics were compiled for demographic data. RESULTS: Of 2872 CNAs, 1579 completed the survey, for a 55% response rate. Results of regression analyses suggest that higher (more developed and more desirable) CNA PSC scores were associated with increased reporting of falls (B = 0.015; P = .000). Facilities with higher total CNA PSC scores were more likely to report moderate restraint use, whereas facilities with lower CNA PSC scores were more likely to report high restraint use (B = 0.172; P = .017). CNA PSC scores were not associated with differences in pressure ulcer rates. CONCLUSIONS: This study represents an important step in the evaluation of CNA PSC in nursing homes and shows that a relationship exists between PSC and selected clinical outcomes. Future work on nursing home PSC and additional clinical as well as workforce outcomes is indicated.