Health and social care actors: Pay heed to safety incidents – transparency benefits the entire sector

The Safety In­ves­ti­ga­tion Au­thor­ity, Fin­land has com­pleted its in­ves­ti­ga­tion into the death caused by chem­i­cal poi­son­ing of an el­derly cus­tomer in a nurs­ing home in South Savo. In No­vem­ber 2022, a client was ex­posed to con­sumer chem­i­cals in the early hours of the morn­ing and died two days later in hos­pi­tal de­spite prompt ac­cess to treat­ment.

The nursing home did not identify the safety risks associated with the use of consumer chemicals and their storage in unlocked spaces. Instead of using the services of a maintenance company, the staff resorted to using chemicals to unblock the sink, which was frequently blocked. Consumer chemicals were stored in kitchen drawers, which were kept unlocked and could be easily accessed. The safety instructions provided to the nursing home staff did not include instructions on the use and storage of chemicals.

“Simple client safety risks in the residential environment of a nursing home are not always identified in risk assessments. In this respect, the social and health care service providers’ self-monitoring guidelines should be developed. At present, efforts to streamline everyday routines sometimes lead to spontaneous solutions that do not take safety into account sufficiently,” states Chief Safety Investigator Hanna Tiirinki.

The investigation also highlighted the inadequacy of data collection and sharing systems.

“Social and health care services should better recognise the safety risks of everyday living environments, beyond those related to mobility. Information on the risks associated with consumer chemicals is not systematically shared and best practices are not spread among service providers,” Tiirinki emphasises.

“The recommendations of the Safety Investigation Authority address the need for more accurate identification of risks in the residential environment and learning from incidents in the sector at large,” Tiirinki adds.