Medical errors: Hospitals often drop the ball with dementia patients

Too many "near misses" involving dementia patients occur in hospital settings, and the number is likely underreported, according to a new report from the Pennsylvania Patient Safety Authority.

Michelle Feil, R.N., a senior patient safety analyst with the authority, analyzed hospital data spanning from January 2005 to December 2014. She found more than 3,700 adverse events involving patients with either confirmed or potential unrecognized dementia. Of these, nearly 3 in 4 involved falls or bed sores. Only 63 were attributed to healthcare workers' unawareness of a patient's dementia. Dementia is a major driver of patient mortality rates, admissions and emergency department use.

Feil's research found that errors involving patients with dementia fell into five categories. Hospitals failed to:

  • Share dementia diagnoses and associated risks with other members of the healthcare team
  • Assess patients' competence or decision-making ability
  • Identify pre-existing dementia in patients
  • Find a dependable health historian or surrogate decision-maker
  • Contact a dependable historian or surrogate

Overall, Feil estimated, doctors fail to identify dementia in outpatients anywhere from 19 to 67 percent of the time. Some hospitals have addressed such risks by putting identifying stickers on dementia patients' wristbands, according to, but Feil is unconvinced such a strategy would be effective. Instead, she told the publication, research indicates such precautions have caused widespread confusion during care transitions.

"We at the authority aren't suggesting that people add another wristband," she said.

Instead, Feil suggested, hospitals should implement dementia screenings for every patient over a certain age, ideally around 65, and create a system for imparting the results to everyone on the treatment team. A similar screening should assess patients' capability to make their own decisions. Providers should keep an eye out for numerous red flags among elderly patients in emergency settings in particular, FierceHealthcare previously reported, such as low blood pressure, cognitive impairment and elevated heart rates.  

To learn more:
- read the report abstract
- here's the article