A family member of a patient with dementia contacted the Pennsylvania Patient Safety Authority and described several "near miss" patient safety events in which hospital staff obtained inaccurate information from the patient, unaware of the patient's dementia diagnosis. Healthcare facilities reported 3,710 events through the Pennsylvania Patient Safety Reporting System between January 2005 and December 2014 involving patients with dementia or potentially unrecognized dementia. Analysts reviewing these reports found 63 similar events in which hospital staff obtained inaccurate information or consent from these patients. Five failure modes were identified: (1) failure to recognize preexisting dementia; (2) failure to assess competence and decision-making capacity of patients with dementia; (3) failure to identify a reliable historian or surrogate decision maker for patients with dementia; (4) failure to contact a reliable historian or surrogate decision maker when information or consent was required for care; and (5) failure to communicate the patient's dementia diagnosis, competence, and decision-making capacity with all members of the healthcare team. Risk reduction strategies targeting these failure modes include screening for dementia, assessing capacity, identifying and communicating with surrogate decision makers, and standardizing communication of a patient's dementia diagnosis with all hospital staff.
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