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 and ideas can be effective in reducing the incidence of geriatric syndromes in older people in the hospital. For example, there is a growing amount of work on the role that design of the hospital environment can play in preventing falls and delirium in terms of ensuring adequate lighting, noise reduction, orientation boards, suitable hospital beds, appropriate flooring, and signage.
Advances in technology can reduce errors by improving communication, providing reminders, making knowledge more readily accessible, prompting for key information, assisting with calculations, monitoring and checking in real time, and providing decision support59. There are many examples of how technology has helped to counteract the cognitive errors that humans can be prone to make, such as the use of barcodes in blood transfusions. Technology can also enhance the human qualities of judgement and decision‐making, such as with computerized decision support with systems for diagnosis, reminder systems for prevention, systems for disease management, and systems for supporting prescribing and drug dosing.60 Any organisation needs a framework for safety measurement and monitoring, as described by The Health Foundation.61 Five dimensions of such a framework include assessment of past harms, reliability, sensitivity to operations, anticipation and preparedness, and integration and learning.
Improving systems of care for older people
Technological advances are also making it possible to redesign systems of care for older people with the aim of providing more targeted and integrated health and social care. For example, the rapidly growing field of telecare has made it possible for older people with sub‐acute problems to be cared for in their homes, in ‘virtual wards’, thereby avoiding unnecessary hospital admissions.
In the hospital, much effort has been made in recent years to implement new ways of caring for acutely ill elderly patients to minimize functional decline during hospitalization and subsequent rehabilitation. For example, it is now common practice for most hospitals in the UK to have an orthogeriatric service to ensure optimal medical care from admission to discharge for elderly patients who have sustained a fractured neck or femur. Stroke units are another example of how specialist care with
