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design of the hospital environment plays an important part in providing adequate isolation and cleaning facilities and allowing sterile practices to be carried out with minimal contamination. Other innovations include using decision‐support systems in antibiotic prescription and allowing patients to participate in infection control initiatives (although older people may be less willing or able to do this).

      Medication safety

      Reducing medication errors requires a multifaceted approach involving computerized systems, simplification and standardization of clinical processes, education and training, and wider cultural and organizational change.⁷⁰

      Much work has been carried out to reduce medication errors in general. The underlying principles are common to all successful safety and quality improvement processes: systems must be designed to prevent errors from occurring in the first place, make errors more visible when they occur, and limit the effects of errors so they do not lead to harm. Standardization of processes, paying particular attention to high‐risk medications, and involvement and collaboration with both patients and clinicians have been shown to be successful strategies.

      Several categories of interventions have been shown to maximize medication safety for older people in particular. Much as for falls or delirium, the first step is to identify and prevent inappropriate prescribing. Assessment instruments such as the Beers Criteria, Screening Tool of Older Persons' Prescriptions (STOPP), and Screening Tool to Alert to Right Treatment (START)⁷¹ give lists of drugs to avoid in older patients. These tools are useful for both the prevention and measurement of inappropriate prescribing. The potential drawbacks of such tools are that they may not be internationally useable, they rely on correct usage by prescribers, and they may not include all classes of relevant drugs.

      A crucial intervention to improve medication safety in older people is medication review and medicines reconciliation, both of which should ideally occur routinely at transitions of care and form a crucial part of specialist geriatric assessment. In primary care, various measures have been shown to improve overall medication safety in older patients, including clinical pharmacist intervention, educational measures, and computerized support.³³ As described earlier, one of the problems in assuring appropriate prescribing for older people is that they have often been excluded from relevant large clinical trials, leading to uncertainty about the safest way to prescribe for them. However, this trend seems to be reversing of late, with older people being specifically targeted for recruitment into such trials.⁴⁷

      Patient safety issues in community settings

      Perhaps the most vulnerable elderly population are those who reside in care homes; here, patient safety issues are likely to be similar to those encountered in hospitals in terms of geriatric syndromes, risks associated with immobility and functional decline, and adverse drug events. There are, however, crucial differences that are likely to affect patient safety in care homes compared with hospitals: in this environment, things move at a different pace, the majority of patients are frail, responsibilities and expertise amongst staff are different, and problems with the management and diagnosis of acute problems also differ.

      Falls‐prevention trials in care homes have focused on a variety of interventions. Dyer, et al. trialled a multicomponent falls‐prevention programme that showed some benefit in falls prevention but did not reach statistical significance.⁷² Although feasibility trials looked promising, a recent Cochrane meta‐analysis concluded that the evidence was uncertain regarding the effect of exercise, medication review, or multifactorial interventions on fall rates.⁷³ Care home residents are also at risk of medication‐related side effects due to multimorbidities and polypharmacy. A recent clinical trial showed that multi‐professional medication reviews improved medication appropriateness in care home residents but failed to improve clinical outcomes and were costly.⁷⁴ Embedding quality improvements by providing training and intensive facilitator support to care homes showed trends toward reducing adverse events in the Safer Provision and Caring Excellence (SPACE) programme in England.⁷⁵ Harnessing quality‐improvement techniques and allowing flexibility of interventions by empowered staff may pave the way to effective interventions.

      Although large amounts of patient‐related data are created in primary care, this information is not used effectively to measure adverse events.⁷⁶ Standardised definitions of adverse events are lacking in home‐care settings, and intervention studies are sparse. This is especially true for people with dementia. A range of issues have been identified, including inter‐professional communications, medications errors, carer stress, and unclear service pathways.⁷⁷ Professionals and caregivers have different attitudes about balancing safety with autonomy and who is responsible for safety. Further research is needed in measuring patient adverse events in primary care and interventions to reduce them.

Priorities for improving the safety and quality of care for older people

      Patient safety for older people across the world

      Of course, patient safety is a global priority of concern to older people and healthcare services worldwide. More research is required to understand the patient safety issues particularly relevant to older people in developing countries.

      Improved definitions and measurement

      To understand and improve safety and quality of care for older people, particularly those who are frail and complex, it is crucial that we consider further what safety and quality actually mean in this population. As described earlier, existing ways of measuring safety in hospitals, particularly through case record review or reporting, are not very good at detecting the complex geriatric syndromes that are important to these patients and the healthcare system. This is not surprising, considering that such measures were not originally developed with the frail older person in mind. Very few adverse events associated with poor clinical reasoning, communication skills, or safety awareness are detected by the usual methods of clinical incident reporting.

      The complex nature of frail older patients can lead to difficulties unravelling cause and effect when trying to assess safety in these patients. Another complicating factor is that the boundaries are blurred between adverse outcomes of hospitalization that are not preventable, preventable adverse events, and providing high‐quality service.

      Current measures of quality of care for older people tend to assess the management of specific clinical problems across healthcare sectors, such as the national audits of stroke, falls and bone health, and incontinence in the UK or the Assessing Care of Vulnerable Elders (ACOVE) measures developed in the US.⁷⁸ There is certainly a need to develop generalizable quality indicators for acutely unwell frail elderly people in the hospital, as highlighted recently by the NHS Confederation in the UK.⁷⁹

      Patient safety research in non‐hospital settings

      Much of this chapter has concentrated on the hospital environment because that is where the majority of patient safety research has been carried out; of course, although the frailest older people tend to undergo hospitalization the most frequently, they also encounter health services in other settings, most notably in intermediate care, primary care, and care homes. Unfortunately, comparatively little research has been carried out on adverse events in older people in these settings, and this needs to be addressed, especially as systems of care are developed to minimize hospital admissions and maximize independence at home for older people. Although work has been done to look at certain aspects of patient safety in these environments, such as medication safety, there is still much to do.

Conclusion

It is clear that although excellent healthcare exists for older people, there are many areas in which further safety and quality improvements can be made for this vulnerable population. As, justly, patient safety and quality of care become the main focus of planners of healthcare services, and with increasing

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