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Original Investigation
July 22, 2019

Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home

Author Affiliations
  • 1Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
  • 2Meyers Primary Care Institute, Worcester, Massachusetts
  • 3Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 4Qualidigm, Wethersfield, Connecticut
  • 5School of Public Health and Health Sciences, University of Massachusetts, Amherst
JAMA Intern Med. 2019;179(9):1254-1261. doi:10.1001/jamainternmed.2019.2005
Key Points

Question  What is the incidence, type, severity, and preventability of adverse events in long-term care residents transitioning from hospital back to long-term care?

Findings  This prospective cohort study of 555 long-term care residents contributing 762 discharges found that adverse events developed 37.3% of the time. Of these events, 70.4% were preventable or ameliorable, with skin tears, pressure ulcers, and falls being the most common events.

Meaning  Transition back to long-term care is a high-risk period; standardized reporting of events and better coordination and information transfer across settings are potential ways to prevent adverse events in this vulnerable population.


Importance  Transition from hospital to nursing home is a high-risk period for adverse events in long-term care (LTC) residents. Adverse events include harms from medical care, including failure to provide appropriate care.

Objective  To report the incidence, type, severity, and preventability of adverse events in LTC residents transitioning from hospital back to the same LTC facility.

Design, Setting, and Participants  Prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017, and followed up for 45 days. In a random sample of 32 nursing homes located in 6 New England states, 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility.

Main Outcomes and Measures  The main outcome was an adverse event within the 45-day period after transition from hospital back to nursing home. Trained nurse abstractors reviewed nursing home records for the period, and then 2 physicians independently reviewed each potential adverse event to determine whether harm occurred and to characterize the type, severity, and preventability of each event. When reviewers disagreed, they met to reach consensus.

Results  Of the 555 individual residents, 365 (65.6%) were female, and the mean (SD) age at the time of discharge was 82.2 (11.5) years. Five hundred twenty (93.7%) were non-Hispanic white, 21 (3.8%) were non-Hispanic black, 9 (1.6%) were Hispanic, and 5 (0.9%) were of other non-Hispanic race/ethnicity. In the cohort, there were 379 adverse events among 762 discharges. One hundred ninety-seven events (52.0%) related to resident care, with pressure ulcers, skin tears, and falls with injury representing the most common types of events in this category. Health care–acquired infections (108 [28.5%]) and adverse drug events (64 [16.9%]) were the next most common. One hundred ninety-eight (52.2%) adverse events were characterized as less serious. However, 145 (38.3%) events were deemed serious, 28 (7.4%) life-threatening, and 8 (2.1%) fatal. In terms of preventability, 267 (70.4%) adverse events were found to be preventable or ameliorable, with less serious events more often considered preventable or ameliorable (146 [73.7%]) compared with more severe events (121 [66.9%]). In addition, resident care–related adverse events such as fall with injury, skin tear, and pressure ulcer were more commonly deemed preventable (173 of 197 [87.8%]) compared with adverse drug events (39 of 64 [60.9%]) or health care–acquired infections (49 of 108 [45.4%]).

Conclusions and Relevance  Adverse events developed in nearly 4 of 10 of discharges from hospital back to LTC. Most were preventable or ameliorable. Standardized reporting of events and better coordination and information transfer across settings are potential ways to prevent adverse events in LTC residents.

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