An Action Research for Patient Safety and Service Quality in Nursing Homes

  • G. Lefosse
  • L. Rasero
  • L. Belloni
  • E. Baroni
  • M. Matera
  • E. Beleffi
  • S. Paiva
  • L. Brizzi
  • T. BellandiEmail author
Conference paper
Part of the Advances in Intelligent Systems and Computing book series (AISC, volume 818)


The objective of this study is redesigning quality and safety of care in Nursing Homes (NH), through a participatory approach based on human factors and ergonomics principles and techniques. We started with an in-deep qualitative analysis of daily practices in 4 nursing homes, selected on the basis of their performance (good and bad) and location (urban and rural). Then we performed on-site observations and ethnographic interviews with workers and patients. To conduct the explicit, non-participant observations, an original grid was developed, inspired by the definition and dimensions of quality. The crude notes of observations were subsequently re-aggregated on the grid by themes and dimensions of the observation scheme, then subjected to expert reviewers who evaluated weaknesses and strengths. According to experts’ review, the most relevant safety related themes are infections and falls prevention, quality of nutrition, behavioural disorders and management of emergencies. On the basis of the elaboration of data, we then designed a multidimensional intervention encompassing interactive training sessions, scenario based redesign of weak care processes, supervision and feedback to front-line workers and management. A follow-up session is scheduled to monitor progress on site and provide feedback, as well as an evaluation of sensitive indicators at the intervention sites compared to the regional benchmark. Pilot study shows feasability of the intervention and active participation of the involved workers.


Nursing home Long-term care Patient safety Multidimensional intervention 


  1. 1.
    Castle NG, Sonon KE (2006) A culture of patient safety in nursing homes. Qual Saf Health Care 15(6):405–408CrossRefGoogle Scholar
  2. 2.
    Masotti P, McColl MA, Green M (2010) Adverse events experienced by homecare patients: a scoping review of the literature. Int J Qual Health Care 22(2):115–125CrossRefGoogle Scholar
  3. 3.
    Gartshore E, Waring J, Timmons S (2017) Patient safety culture in care homes for older people: a scoping review. BMC Health Serv Res 17(1):1–11CrossRefGoogle Scholar
  4. 4.
    Panagioti M, Blakeman T, Hann M, Bower P (2017) Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional study. BMJ Open 7(5):1–9CrossRefGoogle Scholar
  5. 5.
    Simmons S, Schnelle J, Slagle J, Sathe NA, David Stevenson M, Carlo M et al (2016) Resident safety practices in nursing home settings. Agency for Healthcare Research and Quality, RockvilleGoogle Scholar
  6. 6.
    Rust TB, Wagner LM, Hoffman C, Rowe M, Neumann I (2008) Broadening the patient safety agenda to include safety in long-term care. Healthc Q 11:31–34CrossRefGoogle Scholar
  7. 7.
    Ouslander JG, Lamb G, Perloe M, Givens JH, Kluge L, Rutland T et al (2010) Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs. J Am Geriatr Soc 58(4):627–635CrossRefGoogle Scholar
  8. 8.
    Saliba D, Kington R, Buchanan J, Bell R, Wang M, Lee M et al (2000) Appropriateness of the decision to transfer nursing facility residents to the hospital. J Am Geriatr Soc 48(2):154–163CrossRefGoogle Scholar
  9. 9.
    Waal GHD, Naber T, Schoonhoven L, Persoon A, Sauerwein H, Van Achterberg T (2006) Problems experienced by patients receiving parenteral nutrition at home: results of an open interview study. J Parenter Enteral Nutr 30(3):215–221CrossRefGoogle Scholar
  10. 10.
    Shirotani N, Iino T, Numata K, Kameoka S (2006) Complications of central venous catheters in patients on home parenteral nutrition: an analysis of 68 patients over 16 years. Surg Today 36(5):420–424CrossRefGoogle Scholar
  11. 11.
    Wagner LM, Rust T (2008) Safety in long-term care settings: broadening the patient safety agenda to include long-term care services. Canadian Patient Safety InstituteGoogle Scholar
  12. 12.
    Wang KN, Bell JS, Chen EYH, Gilmartin-Thomas JFM, Ilomäki J (2018) Medications and prescribing patterns as factors associated with hospitalizations from long-term care facilities: a systematic review. Drugs Aging 26:1–35Google Scholar
  13. 13.
    Lim RHM, Anderson JE, Buckle PW (2016) Work domain analysis for understanding medication safety in care homes in England: an exploratory study. Ergonomics 59(1):15–26CrossRefGoogle Scholar
  14. 14.
    Alldred DP, Standage C, Fletcher O, Savage I, Carpenter J, Barber N et al (2011) The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. BMJ Qual Saf 20(5):397–401CrossRefGoogle Scholar
  15. 15.
    Tariq A, Georgiou A, Westbrook J (2012) Medication incident reporting in residential aged care facilities: limitations and risks to residents’ safety. BMC Geriatr 12(1):67Google Scholar
  16. 16.
    Axelsson J, Elmstahl S (2004) Home care aides in the administration of medication. Int J Qual Health Care 16(3):237–243CrossRefGoogle Scholar
  17. 17.
    Silvestre JH, Bowers BJ, Gaard S (2015) Improving the quality of long-term care. J Nurs Regul [Internet] 6(2):52–56. Elsevier Masson SASGoogle Scholar
  18. 18.
    Specht JK (2013) Evidence based practice in long term care settings. J Korean Acad Nurs 43(2):145–153CrossRefGoogle Scholar
  19. 19.
    Sohn M, Choi M (2017) Factors related to healthcare service quality in long-term care hospitals in South Korea: a mixed-methods study. Osong Public Health Res Perspect 8(5):332–341CrossRefGoogle Scholar
  20. 20.
    Shin JH, Hyun TK (2015) Nurse staffing and quality of care of nursing home residents in Korea. J Nurs Scholarsh 47(6):555–564CrossRefGoogle Scholar
  21. 21.
    Curatolo N, Gutermann L, Devaquet N, Roy S, Rieutord A (2014) Reducing medication errors at admission: 3 cycles to implement, improve and sustain medication reconciliation. Int J Clin Pharm 37(1):113–120CrossRefGoogle Scholar
  22. 22.
    Arnoldo L, Cattani G, Cojutti P, Pea F, Brusaferro S (2016) Monitoring polypharmacy in healthcare systems through a multi-setting survey: should we put more attention on long term care facilities? J Public Health Res 5(3):104–108CrossRefGoogle Scholar
  23. 23.
    Institute of Medicine (2001) Crossing the quality chasm: a new health system for the 21th century. National Academy Press, Washington, DCGoogle Scholar
  24. 24.
    Vaughn T, Koepke M, Kroch E, Lehrman W, Sinha S, Levey S (2006) Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. J Patient Saf 2(1):2–9Google Scholar
  25. 25.
    World Health Organization (2006) Quality of care: a process for making strategic choices in health systems. World Health Organization, GenevaGoogle Scholar
  26. 26.
    Hutchins E (1995) Cognition in the wild. Massachusetts Institute of Technology Press, CambridgeGoogle Scholar
  27. 27.
    Nuti S, Rosa A, Trambusti B (2014) La mappatura delle residenze per anziani non autosufficienti in Toscana- Report 2014. Laboratorio Management & Sanità, Scuola Superiore Sant’Anna, PisaGoogle Scholar
  28. 28.
    ARS Toscana (2014) Progetto ministeriale CCM: qualità e sicurezzaGoogle Scholar
  29. 29.
    Castle NG, Ferguson, JC (2010) What is nursing home quality and how is it measured? Gerontologist 50(4): 426–442Google Scholar
  30. 30.
    Mor V, Berg K, Angelelli J, Gifford D, Morris J, Moore T (2003) The quality of quality measurement in US nursing homes. Gerontologist 43:S237–S246CrossRefGoogle Scholar
  31. 31.
    McHugh M, Shi Y, Ramsay PP, Harvey JB, Casalino LP, Shortell SM, et al (2016) Patient-centered medical home adoption: results from aligning forces for quality. Health Affairs 35(1):141–149Google Scholar
  32. 32.
    Corbetta P (1999) Metodologia e tecniche della ricerca sociale. Il MulinoGoogle Scholar
  33. 33.
    Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P et al (2000) How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ 320:777Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • G. Lefosse
    • 1
  • L. Rasero
    • 1
  • L. Belloni
    • 2
  • E. Baroni
    • 2
  • M. Matera
    • 3
  • E. Beleffi
    • 4
  • S. Paiva
    • 5
  • L. Brizzi
    • 6
  • T. Bellandi
    • 6
    Email author
  1. 1.School of Nursing SciencesUniversity of FlorenceFlorenceItaly
  2. 2.Regional Referral Centre for Relational Criticalities, Regional Health Service of TuscanyAzienda Ospedaliero Universitaria CareggiFlorenceItaly
  3. 3.Alzheimer Patients’ Association (AIMA)FlorenceItaly
  4. 4.Centre for Clinical Risk Management and Patient Safety, Regional Health Service of TuscanyAzienda Ospedaliero Universitaria CareggiFlorenceItaly
  5. 5.Lisbon School of Public HealthLisbonPortugal
  6. 6.Tuscany Northwest Trust, Regional Health Service of TuscanyLuccaItaly

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