• J H Gurwitz, M T Sanchez-Cross, M A Eckler, and J Matulis.
• Hebrew Rehabilitation Center for Aged, Boston, MA.
• J Am Geriatr Soc. 1994 Jan 1; 42 (1): 33-8.

ObjectiveTo describe the adverse and unexpected events reported by staff over a 1-year period in a large, long-term care institution.DesignA retrospective review of resident incident reports.SettingA 703-bed, academically oriented, long-term care facility.PatientsResidents of the facility have a mean age of 88.5 years, are 76% female, and have an average length of stay of 4.3 years.Measurements And Main ResultsOf the 3,390 adverse and unexpected events reports over the 1-year study period, falls (with and without associated injury) were the most frequently reported incidents, followed by non-fall-related injuries, medication-related events, and wandering episodes. While a large proportion of falls occurred in ambulating residents (47%), the majority occurred under different circumstances including falls from bed, wheelchair, and commode/toilet. Bruises and skin tears were the most frequently reported fall- and non-fall-related injuries. The annual incidence rates for falls, fall-related injuries, and non-fall-related injuries varied according to resident care unit level, with semi-dependent residents experiencing the highest rates of falls and dependent residents experiencing the highest rates of non-fall-related injuries. Circadian patterns in the incidence of these events varied according to resident care level.ConclusionsInformation regarding adverse and unexpected events in the long-term care setting can be organized into databases that allow analysis of patterns and trends. The results of these analyses may be helpful in targeting limited resources to areas of greatest need within an individual institution and for comparing quality of care across different long-term care facilities.

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