Factors That Contribute To Adverse Events Involving Care

224 Pages·2017·10.28 MB·English

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Dorothy J. Gotzmeister, The University of Western Ontario
Supervisor: Dr. Aleksandra A. Zecevic, The University of Western Ontario
A thesis submitted in partial fulfillment of the requirements for the Master of Science degree in
Health and Rehabilitation Sciences
© Dorothy J. Gotzmeister 2013
Follow this and additional works at: https://ir.lib.uwo.ca/etd
Part of the Community Health and Preventive Medicine Commons
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Gotzmeister, Dorothy J., "Factors That Contribute To Adverse Events Involving Care- Dependent
Community Dwelling Older Adults And Their Caregivers." (2013). Electronic Thesis and Dissertation
Repository. 1163.
https://ir.lib.uwo.ca/etd/1163
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FACTORS THAT CONTRIBUTE TO ADVERSE EVENTS INVOLVING CARE-
DEPENDENT COMMUNITY DWELLING OLDER ADULTS AND THEIR
CAREGIVERS

(Thesis format: Monograph)

by

Dorothy Gotzmeister

Graduate Program in Health and Rehabilitation Sciences - Health & Aging

A thesis submitted in partial fulfillment
of the requirements for the degree of
Master of Science

The School of Graduate and Postdoctoral Studies
The University of Western Ontario
London, Ontario, Canada

© Dorothy Gotzmeister 2013
ii

Abstract
The research on home and community care shows that when safely delivered it can be an
efficient way to support elders who require care, potentially preventing a move into costlier
institutional care. Learning from system-wide safety breakdowns that occur is necessary to
establish appropriate prevention strategies. The purpose of this study was to identify the
factors that contributed to adverse events in care-dependent community-dwelling older adults
and their caregivers. Using a multiple case study methodology, eight falls were investigated
using a comprehensive Systemic Falls Investigative Method. Using within case and across
case analyses, a total of 280 contributing factors were identified, and grouped in four distinct
themes of safety deficiencies: Everyday living has become risky, Limitations with
supervision, Disconnects within the system, and Poor fall risk identification and follow-up.
This study provides insights into how and why adverse events occur in home and community
care, allowing for targeted systemic improvements.

Keywords

Older adults, seniors, adults 80+, community care, systems theory, health-related safety,
adverse events, falls, case study research, SFIM.
iii

Co-Authorship Statement
This thesis is the original work of Dorothy Gotzmeister, who is the primary author for all
publications stemming from this material and lead researcher for all aspects of this study.
Creation of this study was shared by D. Gotzmeister and Dr. A. Zecevic.
As thesis supervisor, Dr. Aleksandra Zecevic is a co-author of all ensuing material and
publications of this thesis. In the role of committee members, Prof. Lisa Klinger and Dr. Alan
Salmoni will be offered co-authorship for all ensuing material and publications related to this
thesis.
iv

Acknowledgments
This study is the final product of many minds and helping hands. My first acknowledgment is
a thank you to my advisor, Dr. Aleksandra Zecevic for your guidance and patience, without
you this project would not have been possible.
A thank you also goes to the members of my advisory committee, Professor Lisa
Klinger and Dr. Alan Salmoni, for your thoughts and input, I appreciated them all.
I would also like to acknowledge the members of the East Elgin Family Health Team
and thank them for their keen interest in participating and persistence in recruiting
participants. I could not have done this project without your cooperation.
My gratitude is extended to all the participants in this study, thank you for giving
your time and sharing your experiences with me.
And finally, my family and friends, thank you for listening, proof reading, doing the
dishes, and generally picking up the slack.

In youth we run into difficulties. In old age difficulties run
into us.
Beverly Sills
v

Table of Contents
Abstract ............................................................................................................................... ii
Co-Authorship Statement................................................................................................... iii
Acknowledgments.............................................................................................................. iv
Table of Contents ................................................................................................................ v
List of Tables ..................................................................................................................... ix
List of Figures ..................................................................................................................... x
List of Appendices ............................................................................................................. xi
Chapter 1 ............................................................................................................................. 1
1 Introduction .................................................................................................................... 1
1.1 Literature Review ..................................................................................................... 2
1.1.1 Care Within the Home ................................................................................ 2
1.1.1.1 Formal Homecare ......................................................................... 3
1.1.1.2 Informal Caregivers ...................................................................... 5
1.1.1.3 Not-for-Profit Agencies ................................................................ 6
1.1.2 Safety of Care-Dependent Older Adults in the Home and Community ..... 6
1.1.3 Contributing Factors to Adverse Events ..................................................... 8
1.2 Systems Approach to Investigation of Adverse Events ......................................... 10
1.3 Systemic Investigation Method .............................................................................. 11
1.4 Summary ................................................................................................................ 12
1.5 Purpose ................................................................................................................... 13
1.6 Positioning the Researcher ..................................................................................... 13
Chapter 2 ........................................................................................................................... 14
2 Methods ........................................................................................................................ 14
2.1 Philosophical Anchor ............................................................................................. 14
vi

2.2 Methodology .......................................................................................................... 14
2.3 Procedure................................................................................................................ 15
2.3.1 Setting and Recruitment ............................................................................ 15
2.3.2 Participants ................................................................................................ 16
2.3.2.1 Primary Participants ................................................................... 16
2.3.2.2 Secondary Participants ............................................................... 16
2.3.2.3 Tertiary Workgroup Participants ................................................ 17
2.3.3 Data Collection ......................................................................................... 17
2.3.3.1 Systemic Falls Investigation Method Process ............................ 18
2.3.4 Data Analysis ............................................................................................ 23
Chapter 3 ........................................................................................................................... 25
3 Results .......................................................................................................................... 25
3.1 Primary Participants’ Characteristics ..................................................................... 25
3.2 Secondary Participants’ Characteristics ................................................................. 27
3.3 Characteristics of Falls Investigated ...................................................................... 29
3.4 Narrative Case Summaries ..................................................................................... 31
3.4.1 Mr. Dee (ID 14801) .................................................................................. 31
3.4.2 Mrs. Kay (ID 15522, 15523)..................................................................... 32
3.4.3 Mrs. Bridge (ID 15524) ............................................................................ 36
3.4.4 Mrs. Broom (ID 15525) ............................................................................ 39
3.4.5 Mrs. Peters (ID 16036) ............................................................................. 40
3.4.6 Mrs. Rose (ID 16259) ............................................................................... 41
3.4.7 Mrs. Bee (ID 16383) ................................................................................. 43
3.5 Identified Contributing Factors .............................................................................. 46
3.6 Content Analysis Results ....................................................................................... 46
vii

3.6.1 Coding List Formation .............................................................................. 46
3.6.2 Overarching Themes ................................................................................. 47
3.6.2.1 Everyday Living has Become Risky .......................................... 47
3.6.2.2 Limitations With Supervision ..................................................... 49
3.6.2.3 Disconnects Within the System .................................................. 50
3.6.2.4 Poor Safety Risk Identification and Follow-Up ......................... 52
Chapter 4 ........................................................................................................................... 56
4 Discussion .................................................................................................................... 56
4.1 Review of Study Purpose and Objectives .............................................................. 60
4.2 Implications for Practice ........................................................................................ 61
4.3 Future Research ...................................................................................................... 64
4.4 Limitations to the Study ......................................................................................... 65
4.5 Utility of the SFIM ................................................................................................. 66
Chapter 5 ........................................................................................................................... 68
5 Conclusions .................................................................................................................. 68
Bibliography ..................................................................................................................... 70
Appendices ........................................................................................................................ 79
Appendix A: Adverse Event Definitions From the Literature .......................................... 79
Appendix B: Comparison of Six Studies Examining Adverse Events in Health Care ..... 80
Appendix C: Western University Ethics Board Approval ............................................... 83
Appendix D: Page Given to Family Health Team to Facilitate Participant Recruitment . 84
Appendix E: Letter of Information-Caregiver and Care Receiver With Consent Page .... 85
Appendix F: Contact Information Form ........................................................................... 88
Appendix G: Mini Mental State Exam ............................................................................. 89
Appendix H: Guidelines for Initial Investigation Interview ............................................. 90
viii

Appendix I: Letter of Information-Generic and Consent Page ......................................... 92
Appendix J: Guidelines for Investigative Interview With ‘Others’ .................................. 95
Appendix K: Mr. Dee Full SFIM Report .......................................................................... 96
Appendix L: Mrs. Kay1 Full SFIM Report ..................................................................... 107
Appendix M: Mrs. Kay2 Full SFIM Report .................................................................... 125
Appendix N: Mrs. Bridge full SFIM report .................................................................... 139
Appendix O: Mrs. Broom Full SFIM Report ................................................................. 154
Appendix P: Mrs. Peters Full SFIM Report.................................................................... 167
Appendix Q: Mrs. Rose Full SFIM Report ..................................................................... 179
Appendix R: Mrs. Bee Full SFIM Report ....................................................................... 194
Appendix S: Description of Codes Used to Identify Patterns and Similarities Among
Factors that Contributed to Falls in Older Adults ...................................................... 208
Curriculum Vitae ............................................................................................................ 211
ix

List of Tables
Table 1 Primary Participant Demographics for Falls Investigated With the SFIM ................ 26
Table 2 Summary of Secondary Participants and Description of Additional Data Sources for
Eight Case Studies .................................................................................................................. 28
Table 3 Characteristics of Eight Investigated Falls and Their Consequences ........................ 30