International Journal of Clinical Case Reports 2026, Vol.16 http://medscipublisher.com/index.php/ijccr © 2026 MedSci Publisher, registered at the publishing platform that is operated by Sophia Publishing Group, founded in British Columbia of Canada. All Rights Reserved.
International Journal of Clinical Case Reports 2026, Vol.16 http://medscipublisher.com/index.php/ijccr © 2026 MedSci Publisher, registered at the publishing platform that is operated by Sophia Publishing Group, founded in British Columbia of Canada. All Rights Reserved. MedSci Publisher is an international Open Access publisher specializing in clinical case, clinical medicine, new variations in disease processesregistered at the publishing platform that is operated by Sophia Publishing Group (SPG), founded in British Columbia of Canada. Publisher MedSci Publisher Edited by Editorial Team of International Journal of Clinical Case Reports Email: edit@ijccr.medscipublisher.com Website: http://medscipublisher.com/index.php/ijccr Address: 11388 Stevenston Hwy, PO Box 96016, Richmond, V7A 5J5, British Columbia Canada International Journal of Clinical Case Reports (ISSN 1927-579X) is an open access, peer reviewed journal published online by MedSci Publisher. The journal is considering all the latest and outstanding research articles, letters and reviews in all aspects of clinical case, containing clinical medicine which advance general medical knowledge; the event in the course of observing or treating a patient; new variations in disease processes; as well as the expands the field of clinical relating to case reports. All the articles published in International Journal of Clinical Case Reports are Open Access, and are distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. MedSci Publisher uses CrossCheck service to identify academic plagiarism through the world’s leading plagiarism prevention tool, iParadigms, and to protect the original authors’ copyrights.
International Journal of Clinical Case Reports (online), 2026, Vol. 16, No.2 ISSN 1927-579X http://medscipublisher.com/index.php/ijccr © 2026 MedSci Publisher, registered at the publishing platform that is operated by Sophia Publishing Group, founded in British Columbia of Canada. All Rights Reserved. Latest Content Nursing-Sensitive Indicators and Quality Improvement for Inpatient Adverse Events Among Older Patients Leiming Shen, Mingzi Huang, Yeli Huang International Journal of Clinical Case Reports, 2026, Vol. 16, No. 2, 66-83 The Impact of High-Intensity Interval Training (HIIT) on Endurance and Speed in Adolescent Athletes Abhishek Balo, Tonkey Pegu, Sidhartha Rajbongshi, Pabitra Pran Gogoi, Pranjit Boruah, Arindom Baruah, Mantu Baro, O. Jiten Singh International Journal of Clinical Case Reports, 2026, Vol. 16, No. 2, 84-91 Application Strategies and Efficacy Evaluation of Immunotherapy in the Comprehensive Treatment of Advanced Ovarian Cancer Wei Zhang International Journal of Clinical Case Reports, 2026, Vol. 16, No. 2, 92-107 Artificial Intelligence-Assisted Minimally Invasive Gynecologic Surgery: Rationale and Clinical Context Jingqiang Wang International Journal of Clinical Case Reports, 2026, Vol. 16, No. 2, 108-122 Assessment and Rehabilitation Interventions for Diastasis Recti Abdominis DanXu International Journal of Clinical Case Reports, 2026, Vol. 16, No. 2, 123-139
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 66 Feature Review Open Access Nursing-Sensitive Indicators and Quality Improvement for Inpatient Adverse Events Among Older Patients Leiming Shen1*, Mingzi Huang2*, Yeli Huang3 1 Jingbei Medical Area, Chinese People’s Liberation Army General Hospital, Haidian, 100094, Beijing, China 2 Liuliqiao Outpatient Department, Jingnan Medical Area, Chinese People’s Liberation Army General Hospital, Southern Medical Branch of Chinese PLA General Hospital, Haidian, 100039, Beijing, China 3 The Sixth Medical Center, Chinese People’s Liberation Army General Hospital, Haidian, 100048, Beijing, China *These authors contributed equally to this work Corresponding author: huangyeli88@163.com International Journal of Clinical Case Reports 2026, Vol.16, No.2 doi: 10.5376/ijccr.2026.16.0007 Received: 20 Jan., 2026 Accepted: 28 Feb., 2026 Published: 08 Mar., 2026 Copyright © 2026 Shen et al., This is an open access article published under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Preferred citation for this article: Shen L.M., Huang M.Z., and Huang Y.L., 2026, Nursing-sensitive indicators and quality improvement for inpatient adverse events among older patients, International Journal of Clinical Case Reports, 16(2): 66-83 (doi: 10.5376/ijccr.2026.16.0007) Abstract With the rapid aging of the population, older adults have become a major proportion of hospitalized patients, and their risk of experiencing adverse events during hospitalization is significantly higher than that of other age groups. Adverse events such as falls, pressure injuries, infections, delirium, and medication-related harm not only threaten patient safety but also contribute to prolonged hospital stays, functional decline, and increased mortality, with a substantial proportion considered preventable. Nursing care plays a critical role in both the occurrence and prevention of these events. Nursing-sensitive indicators (NSIs), which reflect changes in patient outcomes influenced by nursing structures, processes, and interventions, provide essential tools for evaluating nursing quality and supporting continuous quality improvement. Based on a comprehensive review of domestic and international literature, this article summarizes the epidemiological characteristics and major risk factors of adverse events among hospitalized older patients. It focuses on the conceptual foundations, key categories, and selection principles of nursing-sensitive indicators related to adverse events, and examines their current applications and limitations in nursing quality evaluation, risk surveillance, and quality improvement initiatives. The findings suggest that establishing an NSI-oriented quality management framework can facilitate early identification of risks and targeted nursing interventions for hospitalized older adults. Future efforts should prioritize the standardization, geriatric specificity, and digital integration of nursing-sensitive indicators to further enhance patient safety and nursing quality in geriatric inpatient care. Keywords Older patients; Adverse events; Nursing-sensitive indicators; Nursing quality; Quality improvement 1 Introduction With the accelerating process of population aging in China, older adults have become an important component of the hospitalized population. A large body of research indicates that, due to multiple factors such as age-related physiological decline, multimorbidity, frailty, complex treatment regimens, and geriatric syndromes, older patients face a significantly higher risk of experiencing adverse events (AEs) during hospitalization than other age groups. Systematic reviews show that in large general studies of adverse events, the incidence of AEs among hospitalized older medical patients is approximately 5%-6%; however, when geriatric syndromes such as falls, delirium, incontinence, and pressure injuries are included within the scope of adverse events, the incidence can be as high as 60%. Common hospital-associated adverse events include infections (e.g., pneumonia, urinary tract infections, sepsis, and wound infections), delirium, falls, pressure injuries, venous thromboembolism, and medication-related harm (Alotaibi et al., 2025). These adverse events not only pose direct threats to patient safety but also lead to prolonged hospital stays, increased healthcare resource utilization, functional decline, and even increased mortality risk. Importantly, a substantial proportion of these events are considered at least partially preventable. Among the many influencing factors, nursing activities are closely associated with both the occurrence and prevention of adverse events in older hospitalized patients. Previous studies have shown that many adverse events occurring during hospitalization-particularly falls, pressure injuries, infections, medication-related harm, and delirium-are strongly associated with inadequate nursing assessment, insufficient ongoing monitoring, and
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 67 delayed interventions. This issue is especially prominent among older patients with cognitive impairment or dementia, who experience higher rates of preventable adverse events such as falls, delirium, and infections, and who often have longer hospital stays, higher readmission rates, and increased mortality risk (Catalán and Oliveira, 2025; Järbrink et al., 2025; Schouten et al., 2025). Collectively, this evidence highlights the central role of nursing safety in the inpatient management of older adults and underscores the need for more targeted indicator systems to systematically evaluate and continuously improve nursing quality and its relationship with adverse events. Nursing-sensitive indicators (NSIs) are quantitative measures that directly or indirectly reflect the structure, processes, and outcomes of nursing care and are primarily influenced by nursing actions, thereby capturing changes in health status that can be modified by nursing practice. Concept analyses and systematic reviews consistently indicate that NSIs provide objective and comparable evidence for nursing quality monitoring, quality improvement, and organizational-level decision-making. Among hospitalized older patients, commonly used and representative nursing-sensitive indicators include fall rates, pressure injury rates, hospital-acquired infections, medication administration errors, length of stay, functional decline, and patient satisfaction (Goes et al., 2023; Wang et al., 2025). In long-term care and residential aged care settings, structured medication reviews, pain, dehydration, urinary tract infections, falls, behavioral symptoms, depression, weight loss, and decline in activities of daily living have been identified through Delphi studies and review research as priority nursing-sensitive quality indicators for frail older populations (Tevik et al., 2023). These indicators encompass key domains in which nursing practice has the greatest potential to prevent harm and maintain functional ability in older adults. In recent years, nursing-sensitive indicators have increasingly become important tools for nursing quality evaluation and continuous quality improvement (QI) both nationally and internationally, and they have been widely applied in geriatric nursing. Existing evidence suggests that structured medication reviews, multifactorial fall risk assessment and prevention bundles, and enhanced identification interventions for adverse drug events-when implemented using nursing-sensitive indicators-can to some extent reduce the occurrence of specific types of adverse events or improve their detection. However, findings remain heterogeneous, and implementation is often challenged by insufficient integration and sustainability issues (Sultana et al., 2025). Moreover, current research on nursing-sensitive indicators is largely fragmented across different care settings and indicator types, and there remains a relative lack of systematic exploration of how to construct and apply comprehensive indicator sets to drive sustained improvements in nursing quality for hospitalized older patients (Tevik et al., 2023; Connolly et al., 2025). Against this backdrop, the present review focuses on nursing-sensitive indicators related to adverse events and nursing quality improvement during hospitalization of older patients. It systematically synthesizes the epidemiological characteristics and preventability evidence of adverse events among hospitalized older adults, with particular attention to high-risk factors such as frailty and cognitive impairment. It identifies key nursing-sensitive indicators closely associated with adverse events in older inpatients and elucidates their conceptual foundations and empirical evidence. Furthermore, it analyzes the current applications and limitations of nursing-sensitive indicators in geriatric nursing quality evaluation and quality improvement practices, and explores their application pathways and future directions in areas including falls, pressure injuries, infections, medication-related harm, functional decline, and patient experience. This review aims to provide evidence-based support and practical guidance for clinical nurses, nursing managers, and policymakers, to promote the standardized and systematic application of nursing-sensitive indicators in the quality management of inpatient geriatric nursing, ultimately improving patient safety and nursing quality for hospitalized older adults. 2 Characteristics of Adverse Events in Hospitalized Older Patients 2.1 Relationship between physiological and psychological characteristics and adverse events Older patients commonly experience multisystem functional decline at the physiological level, which constitutes a fundamental internal basis for the occurrence of adverse events during hospitalization. Aging is frequently accompanied by frailty, multimorbidity, and polypharmacy, leading to reduced physiological reserve and increased vulnerability, thereby significantly elevating the risk of hospital-associated adverse events such as
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 68 healthcare-associated infections, delirium, falls, pressure injuries, and venous thromboembolism. Mechanistically, declines in sensory, neurological, and musculoskeletal function-including visual and auditory impairment, slowed reaction time, impaired balance, and reduced muscle strength-predispose patients to falls and bed-related injuries during mobility, transfers, and activities of daily living. Meanwhile, reduced skin elasticity, impaired local circulation, and malnutrition decrease tissue tolerance to pressure and shear, increasing the likelihood of pressure injury development (Alotaibi et al., 2025). In addition, age-related declines in hepatic and renal function and impaired homeostatic regulation may alter pharmacokinetics and pharmacodynamics, rendering standard treatments more likely to cause harm, particularly in the context of polypharmacy, and increasing the risk of adverse drug reactions (ADRs) and adverse drug events (ADEs). Systematic reviews indicate that the pooled incidence of in-hospital ADRs among older patients is approximately 16%-22%, with most being predictable, dose-related, and at least partially preventable; risk factors include polypharmacy, potentially inappropriate medications, and impaired renal or hepatic function. Psychological and cognitive characteristics also exert a profound influence on the risk of adverse events. Cognitive impairment-including delirium, dementia, and mild cognitive impairment-is common among hospitalized older adults and is associated with a higher likelihood of adverse events, particularly when combined with a high burden of comorbidity. Studies suggest that in cognitively impaired patients, adverse events are more frequently linked to failures in nursing care, allied health management, and organizational processes, such as inadequate supervision, communication breakdowns, and poor care coordination (Schouten et al., 2025). Furthermore, hospitalization itself may initiate a cascade of “hospital-associated harms” that are not fully attributable to the primary illness: functional declines such as confusion, reduced oral intake, incontinence, and falls may trigger further invasive interventions (e.g., restraints, catheterization, enteral feeding), leading to downstream complications such as thromboembolism and infection. Emotional distress, sleep deprivation, sensory overstimulation or deprivation, and unfamiliar environments may exacerbate delirium and behavioral symptoms, thereby increasing the risk of falls, medication errors, and the use of high-risk psychoactive medications (Schattner, 2023). 2.2 Common types of adverse events during hospitalization and their causes Hospitalized older patients experience a wide spectrum of adverse events, encompassing both traditional medical complications and geriatric syndromes such as falls, delirium, and pressure injuries, as well as infections, medication-related harm, and procedure- or intervention-related complications. Systematic reviews indicate that healthcare-associated infections, delirium, falls, pressure injuries, and venous thromboembolism constitute the most common adverse event profile. In acute geriatric wards, more than half of patients may experience at least one medical adverse event, with infections and delirium being particularly prevalent and often iatrogenic in nature (Alotaibi et al., 2025). Regarding medication safety, reviews suggest that approximately one in every five to six hospitalized older patients experiences an in-hospital adverse drug reaction, manifesting as fluid and electrolyte disturbances, gastrointestinal symptoms, renal impairment, hypotension, or delirium. Diuretics, antimicrobials, antithrombotic agents, and analgesics-particularly opioids and sedatives-are most frequently implicated (Cosgrave et al., 2025). From an etiological perspective, adverse events typically arise at the intersection of patient vulnerability, care processes, and organizational systems. Patient-related factors such as frailty, advanced age, disease or injury severity, and multimorbidity independently increase the risk of unplanned adverse events, including infections, pressure injuries, malnutrition, and urinary retention (Alotaibi et al., 2025). Medication-related factors-such as polypharmacy, potentially inappropriate prescribing, prior fall history, and poor adherence-can further amplify ADE and ADR risk in the absence of adequate medication review and monitoring (Wang et al., 2025). Organizational factors include missed nursing care, staffing shortages, inadequate monitoring, and failures in care coordination. Particularly among cognitively impaired patients, adverse events are more frequently attributable to nursing and organizational causes and are considered highly preventable (Schouten et al., 2025; Järbrink et al., 2025). Additionally, hospitalization-related stressors-such as restricted mobility, invasive devices, sleep deprivation, and unnecessary tests or procedures-may precipitate delirium, deconditioning, and falls, increasing the risk of post-discharge complications (Schattner, 2023).
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 69 2.3 Impact of adverse events on prognosis and nursing quality in older patients The occurrence of adverse events during hospitalization has a substantial negative impact on outcomes in older patients and is closely associated with prolonged length of stay, functional decline, and increased mortality risk. Prospective studies indicate that older patients experiencing medical adverse events have nearly double the length of hospital stay and significantly higher in-hospital mortality; even after adjustment for disease severity and functional status, adverse events are associated with an approximately threefold increase in mortality risk. Review studies further suggest that adverse events often trigger unnecessary interventions and complications, resulting in marked prolongation of hospitalization, with rates of functional disability or death ranging from 5% to 27% among injured older patients. Among geriatric trauma patients, the incidence of nursing-sensitive adverse events is approximately 30% and is associated with significantly longer hospital stays (17 days vs. 6 days), greater frailty, and higher injury severity, underscoring their prognostic significance (Järbrink et al., 2025). Hospitalizations related to ADEs in older adults are also associated with higher healthcare costs and increased need for post-discharge care, such as institutional placement or home care services (Cosgrave et al., 2025). From a nursing quality perspective, adverse events serve both as critical signals of suboptimal nursing care and as factors that further consume nursing resources and strain healthcare systems. Falls, pressure injuries, infections, malnutrition, bladder overdistension, delirium, and adverse drug reactions are all classic nursing-sensitive outcomes, closely linked to the quality of nursing assessment, ongoing surveillance, timely intervention, and care coordination (Alotaibi et al., 2025; Järbrink et al., 2025). High adverse event rates often indicate missed or delayed nursing care, insufficient implementation of preventive measures, and inadequate medication management. This pattern is particularly evident among cognitively impaired patients, in whom nursing- and organization-related adverse events account for a larger proportion, revealing gaps in individualized supervision, communication, and environmental adaptation (Schouten et al., 2025). Conversely, strengthened nursing interventions-such as comprehensive geriatric assessment, proactive pharmacovigilance, early mobilization, and seamless care transitions-have the potential to reduce adverse events, improve functional trajectories, lower readmission risk, and enhance patient satisfaction (Schattner, 2023). 3 Nursing-Sensitive Indicators Related to Adverse Events in Older Patients 3.1 Concept of nursing-sensitive indicators and principles for indicator selection Nursing-sensitive indicators (NSIs) refer to changes in health status or care processes that can be directly influenced by nursing care, and they constitute a core foundation for monitoring nursing quality and performance. Within Donabedian’s “structure-process-outcome” framework, NSIs typically span three dimensions: structural indicators (e.g., nurse staffing levels and skill mix), process indicators (e.g., risk assessment, ongoing monitoring, patient education, nursing communication, and care coordination), and outcome indicators (e.g., falls, pressure injuries, infections, satisfaction, and functional decline) (Baillie et al., 2025). Compared with broader quality indicators, the defining feature of NSIs is that there is an empirically supported association between nursing inputs and patient outcomes, and the indicator content explicitly targets professional nursing practice, thereby enabling a more precise estimation of nursing’s independent contribution to patient outcomes. Accordingly, in the inpatient geriatric context, NSIs are not only used to describe the level of adverse event occurrence but, more importantly, to use quantitative evidence to elucidate the pathways through which nursing interventions contribute to risk control and functional preservation, providing actionable levers for quality improvement. Selection of NSIs in geriatric care should follow principles of scientific rigor, relevance, and feasibility, while ensuring that indicators are truly “nursing-sensitive.” International and national experiences in indicator development emphasize that NSIs should: (1) be clearly and modifiably influenced by nursing; (2) focus on high-incidence or high-risk problems; (3) sensitively discriminate differences in nursing quality; and (4) have reliable, standardized data sources and operational definitions that support continuous measurement and inter-institutional comparison (Tevik et al., 2023). Delphi studies further propose that indicator selection should incorporate clinical relevance, modifiability by nursing, alignment with professional standards, and potential value for benchmarking and quality improvement. For hospitalized older adults, indicator selection should also reflect a risk-oriented and population-specific approach: priority should be given to indicators that capture key geriatric
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 70 characteristics such as frailty, cognitive impairment, mobility limitation, and functional decline, and risk stratification and risk adjustment should be incorporated based on illness severity and nursing dependency to enhance interpretability and managerial utility (Connolly et al., 2025). 3.2 Key nursing-sensitive indicators closely related to adverse events in older patients In older populations, NSIs largely concentrate on nursing-sensitive adverse events and functional outcomes that are closely tied to nursing surveillance, prevention, and coordination. Major reviews and concept analyses repeatedly identify the most commonly used core NSIs in inpatient settings as falls, pressure injuries, healthcare-associated infections, medication administration errors, length of stay, and patient satisfaction. Among these, fall rates reflect the combined effectiveness of nursing practice in risk assessment, environmental management, rounds and observation, medication-risk identification, and safety education. Continuous monitoring of fall incidence and injury severity helps identify high-risk subgroups and time periods and evaluate the implementation of multifactorial prevention bundles. Similarly, pressure injury incidence and the proportion of newly acquired pressure injuries are important indicators of geriatric nursing quality because they are strongly associated with nursing processes such as repositioning, skin assessment, pressure-relieving interventions, and nutritional support. Linking outcome indicators with process indicators (e.g., repositioning adherence rates and completion rates of pressure injury risk assessment) enables a more comprehensive evaluation of intervention effectiveness. In response to the risk profile of older adults, contextualized studies have further expanded the scope of inpatient NSIs to include delirium, frailty, functional decline, malnutrition, bladder overdistension, and readmission, given their high prevalence and substantial preventability under high-quality nursing care (Connolly et al., 2025). For example, in older surgical patients, frailty is significantly associated with the incidence of nursing-sensitive indicators such as in-hospital falls, delirium, pneumonia, and pressure injuries, suggesting that integrating “frailty assessment + NSI monitoring” may trigger earlier individualized preventive nursing care. In older trauma patients, nursing-sensitive adverse events (e.g., healthcare-associated infections, pressure injuries, malnutrition, and urinary retention) occur frequently and are significantly associated with advanced age, frailty, greater injury severity, and longer length of stay, further indicating that these indicators are highly sensitive to nursing care processes (Järbrink et al., 2025). In addition, in long-term care and residential aged care settings, consensus studies emphasize prioritizing systematic medication review, pressure injuries, pain, dehydration, urinary tract infections, fecal impaction, behavioral symptoms, depression, weight loss, decline in activities of daily living (ADL), falls, and restraint use as nursing-sensitive quality indicators for frail older residents (Tevik et al., 2023). Community nursing and home-care research further highlights that “positive outcomes” such as autonomy, participation in decision-making, level of activity participation, quality of end-of-life care, and adherence to care are also important nursing-sensitive outcomes, moving beyond single adverse events to capture older patients’ overall experience and benefits from care (Goes et al., 2023). Overall, constructing multi-indicator portfolios helps more comprehensively cover the risk and outcome spectra of hospitalized older patients and jointly incorporate adverse event prevention and functional preservation into the nursing quality evaluation framework (Gormley et al., 2024). 3.3 Value of nursing-sensitive indicators for risk early warning and quality management NSIs have important value for early warning of adverse event risks in older patients by translating patterns of nursing-sensitive adverse events into actionable risk signals. Indicators such as falls, pressure injuries, delirium, pneumonia, urinary tract infections, malnutrition, and bladder overdistension can conceptually be regarded as manifestations of “failure to maintain,” signaling potential missed nursing care, insufficient allocation of nursing resources, or deterioration of the care environment; thus, they can be used to identify high-risk subgroups and trigger preventive measures in advance (Järbrink et al., 2025; McCauley et al., 2025). For example, when a ward shows an abnormal increase in fall rates or unplanned device removal, or when process indicators (e.g., completion of risk assessment and adherence to prevention bundles) decline, root-cause analysis and targeted interventions can be initiated, enabling a shift from “post-event response” to “pre-event prevention”.
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 71 At the level of nursing quality management, NSIs provide a structured framework for planning, implementing, and evaluating continuous quality improvement (QI). National and institutional practices show that developing nursing process indicators and indicator systems tailored to older-adult services can send “strong signals” regarding improvement priorities, guiding intervention design, staff training, and resource allocation (Baillie et al., 2025). Long-term care facilities and national indicator programs further demonstrate that consensus-based NSI portfolios covering medication review, pressure injury prevention, infection, pain, hydration, function, and social participation not only support inter-institutional benchmarking and system-level improvement, but also expose methodological and feasibility challenges in indicator development and implementation (Tevik et al., 2023). Therefore, NSI-driven quality management should not remain at the level of outcome reporting; rather, it should be integrated with governance structures (e.g., quality committees and risk management teams) and action mechanisms (feedback-review-improvement) to establish a sustainable closed-loop management cycle (Mohan et al., 2024) (Table 1). 4 Nursing Quality Analysis Based on Nursing-Sensitive Indicators 4.1 Data collection and analytical methods for nursing-sensitive indicators Data collection for nursing-sensitive indicators (NSIs) constitutes the foundation of nursing quality analysis, and its scientific rigor and standardization directly determine the credibility and applicability of analytical findings. In the context of inpatient care for older adults, NSI data are typically derived from multiple sources, including nursing documentation and electronic health records (EHRs), adverse event/near-miss reporting systems, clinical quality registries, and standardized assessment tools. The literature indicates that retrospective medical record review remains an important approach for identifying nursing-sensitive adverse events (NSAEs). In particular, trigger tool-guided chart reviews enable systematic identification of events such as infections, pressure injuries, bladder overdistension, and malnutrition, and can be used to calculate incidence rates and compare vulnerability profiles between patients with and without events (Järbrink et al., 2025). At the macro level, regional or national quality registries allow for long-term, structured data accumulation. For example, Sweden’s Senior Alert continuously collects risk assessments and follow-up outcomes related to pressure injuries, malnutrition, falls, and oral health, providing a robust basis for inter-institutional benchmarking and longitudinal trend analysis. In both acute and long-term care settings, standardized outcome assessment tools (e.g., functional status or symptom scales) have demonstrated good reliability and sensitivity to change when routinely used by nurses, supporting nurse-led routine NSI data collection. To ensure comparability across time periods, wards, and institutions, standardized indicator definitions, numerator and denominator rules, event adjudication criteria, and data dictionaries should be established at the organizational or system level. In addition, training nurses on indicator concepts and reporting standards is essential to reduce bias arising from subjective interpretation. With regard to incident reporting, studies suggest that punitive climates and fear of blame may lead to underreporting and undermine the value of data for learning and improvement; therefore, fostering a non-punitive reporting culture should be incorporated into data quality assurance systems (Huang et al., 2025; Wang et al., 2025). Analytically, a stepwise approach combining descriptive epidemiology, multivariable modeling, and benchmarking enables progression “from description to explanation.” Descriptive statistics are used to present incidence rates, distributions, and trends of events such as falls, pressure injuries, infections, medication errors, and bladder overdistension, with stratification by age, frailty status, disease or injury severity, and care setting to identify risk clustering and vulnerable subgroups (Järbrink et al., 2025). Multivariable models (e.g., logistic or Cox regression) further identify patient- and institution-level predictors of serious adverse events and explore associations between NSIs and staffing levels or organizational characteristics, thereby providing more explanatory evidence for management decision-making. Importantly, cross-sectional nurse survey studies have linked missed or unfinished nursing care with increased frequencies of medication dosing errors, hospital-acquired infections, and injurious falls, demonstrating that process gaps can be quantified through NSIs and used to target quality improvement interventions.
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 72 Table 1 Core nursing-sensitive indicators (NSIs) for hospitalized older adults Domain Core NSI Indicator Indicator Description Modifiable Nursing Targets Data Source Recommended Metric Structure Geriatric-trained nurse staffing ratio Proportion of nurses with geriatric care qualifications Nurse staffing and competency management Human resources system Percentage (%) Nursing staff training coverage Completion of geriatric and safety-related training Continuing education and skill development Training management records Compliance rate (%) Availability of fall- and pressure-injury-prevention equipment Adequacy and accessibility of protective equipment Equipment allocation and maintenance Nursing management records Availability rate (%) Process Fall risk assessment compliance Completion of standardized fall risk assessments Risk screening and ongoing reassessment Electronic medical records Compliance rate (%) Pressure injury risk assessment compliance Use of tools such as the Braden scale Early identification of high-risk patients Electronic medical records (EMR) Compliance rate (%) Appropriate restraint use compliance Adherence to indications and protocols for restraints Alternatives to restraints and monitoring Nursing documentation Compliance rate (%) Medication administration safety compliance Double-checking and safe administration of high-risk medications Medication verification and patient education Electronic medical records (EMR) Compliance rate (%) Outcome In-hospital fall incidence rate Falls occurring during hospitalization Environmental safety and nursing surveillanc Adverse event reporting system Incidence per 1000 patient-days Hospital-acquired pressure injury incidence rate New pressure injuries developed during hospitalization Repositioning and skin care interventions Adverse event reporting system Incidence per 1 000 patient-days Nursing-related infection rate Infections associated with nursing procedures Aseptic technique and device care Infection control system Incidence per 1000 patient-days Overall nursing adverse event rate Falls, pressure injuries, medication errors, etc Comprehensive nursing quality improvement Adverse event reporting system Incidence per 1 000 patient-days Meanwhile, national indicator programs that monitor long-term trends and conduct inter-institutional benchmarking can identify quality improvement priorities and research gaps, offering macro-level evidence to support sustained improvement efforts. With advances in information technology, multidimensional data integration and visualization have become increasingly important tools in nursing quality management. Embedding NSIs into information systems and applying statistical process control (SPC) methods (e.g., control charts) for real-time or periodic monitoring facilitates early detection of abnormal variation, triggers root cause analysis, and supports evidence-based decision-making, thereby promoting a shift from “outcome reporting” to “process governance” in quality management (Figure 1). 4.2 Current status of nursing quality and adverse event occurrence in hospitalized older patients Existing research and quality monitoring evidence indicate that preventable nursing-sensitive adverse events remain common among hospitalized older adults, with substantial variation across wards and institutions, reflecting persistent gaps in nursing quality. In studies of geriatric trauma patients, approximately 30% experienced at least one nursing-sensitive adverse event, most commonly healthcare-associated infections (19%), bladder overdistension (11%), pressure injuries (6%), and malnutrition (5%). Patients who experienced events were older, frailer, more severely injured, and had nearly threefold longer hospital stays than those without events
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 73 (Järbrink et al., 2025). Systematic reviews of hospitalized older medical patients report adverse event rates of approximately 5%-6% in large chart review studies; however, when geriatric syndromes such as falls, delirium, and incontinence are included, incidence rates rise to as high as 60%, suggesting that both traditional complications and geriatric syndromes are important reflections of inadequate nursing quality. In nursing homes and skilled nursing facilities, more than one-third of residents or admissions are affected by adverse events such as falls, pressure injuries, medication errors, and acute infections, with particularly high rates during high-risk periods (e.g., early rehabilitation phases or pandemic conditions). Figure 1 NSI data-to-action loop for quality improvement in geriatric inpatient care NSI-based evaluations also reveal variability in nursing performance and the problem of “incomplete monitoring.” A large U.S. hospital survey showed that key nursing activities such as patient education, discharge preparation, and care planning were frequently left unfinished; higher levels of missed nursing care were associated with increased rates of medication errors, hospital-acquired infections, and injurious falls, indicating that process-level nursing gaps translate into measurable safety outcomes. In long-term care settings, serious adverse events are often concentrated in medication errors, falls, delayed or inappropriate interventions, and missed care, and are closely associated with inadequate staff competence, incomplete documentation, and deficiencies in teamwork and communication. Moreover, national-level NSI trend analyses suggest that routine monitoring covers only a small fraction of potential indicators, that mental health-related indicators are frequently absent, and that post-complication mortality has increased over time-implying that current monitoring systems may capture only part of the nursing quality landscape in geriatric care. 4.3 Major problems and weak points in nursing practice At the level of nursing practice, NSI-based analyses consistently expose key vulnerabilities, including missed or delayed nursing care, underreporting of events, and deficiencies in competence and documentation. In hospital settings, higher levels of unfinished nursing tasks-often driven by workload pressures and staffing constraints-are directly associated with increased rates of medication errors, infections, and injurious falls, indicating that monitoring- and prevention-intensive nursing activities are not being reliably delivered. Retrospective studies and incident reports from long-term care facilities further show that serious adverse events are frequently linked to delayed or inappropriate interventions and missed care, with contributing factors including insufficient geriatric assessment and medication management skills, incomplete or missing documentation, weak teamwork, and poor communication. In addition, fear of blame and punitive responses may drive underreporting of events, undermining organizational learning and system-level quality improvement (Huang et al., 2025; Wang et al., 2025).
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 74 A second prominent issue concerns the limited alignment between existing indicator systems and the complex needs of older patients. Review studies highlight that inconsistent NSI definitions, heterogeneous data collection methods, and insufficient evidence of “nursing sensitivity” for some commonly used indicators constrain effective benchmarking and interpretation in geriatric populations. National NSI programs often prioritize a small set of complications while inadequately covering cognitive, psychosocial, and functional outcomes-dimensions that are central to safety and experience in older adults. Furthermore, research on care transitions suggests that adverse events occurring after discharge to nursing facilities are poorly explained by existing institution-level quality scores, implying that critical nursing processes and contextual factors are not fully captured by current quality measurement tools. Overall, although NSIs are powerful management instruments, their potential remains constrained by measurement gaps, reporting culture barriers, and the lack of geriatric-specific, practice-oriented indicators and a supportive safety culture. 5 Development and Implementation of Nursing Quality Improvement Interventions 5.1 Establishing an NSI-oriented quality management mechanism Building a nursing quality management mechanism centered on nursing-sensitive indicators (NSIs) represents a key pathway for driving continuous improvement in adverse events among hospitalized older patients. Concept analyses and studies on indicator application indicate that, for NSIs to fulfill a true governance function, they must be supported by standardized definitions, robust health information systems, and formal reporting linkages to management, thereby enabling routine extraction of nursing performance data, trend analysis, and cross-ward or cross-institutional comparison. In terms of indicator configuration, research from long-term care and residential aged care settings internationally suggests that structured NSI portfolios-such as falls, pressure injuries, infections, dehydration, medication-related problems, pain, and functional decline-can highlight high-risk domains and guide prioritization of quality improvement efforts, demonstrating strong transferability and governance potential (Tevik et al., 2023; Caughey et al., 2025). Accordingly, in the hospital geriatric inpatient context, it is recommended that NSIs closely related to patient safety be incorporated into nursing quality management systems, with explicit definitions, numerators and denominators, data sources, and evaluation cycles specified. This enables the formation of institutionalized and auditable management processes and supports continuous improvement through a closed-loop cycle of “indicator monitoring-problem identification-intervention implementation-outcome evaluation”. With respect to governance structures and operational mechanisms, a mature NSI-oriented system also requires scientifically grounded indicator selection, risk adjustment, and root cause analysis (RCA) processes. Reviews of quality improvement in long-term care note that existing indicators often emphasize safety and effectiveness but may insufficiently capture the breadth of older adults’ needs; therefore, expert consensus methods are needed to optimize indicator sensitivity and interpretability (Caughey et al., 2025). Modified Delphi studies demonstrate that expert panels comprising clinicians, researchers, and family members or caregivers can help prioritize indicators that are genuinely nursing-sensitive, high-incidence or high-risk, and responsive to changes in nursing quality (Tevik et al., 2023). In parallel, governance structures such as multidisciplinary quality committees and dedicated risk management or infection control leads should be established to interpret NSI trends, organize RCAs, and ensure that evidence is translated into revisions of nursing workflows, staffing decisions, and targeted quality improvement (QI) initiatives, rather than remaining at the level of passive reporting. Informatics support is a critical enabler of effective NSI-oriented management. Embedding NSIs within electronic health record systems and deploying visual dashboards can facilitate real-time or periodic monitoring of adverse events in older patients, enable inter-institutional benchmarking, and provide transparent feedback, thereby reducing bias associated with manual data collection and improving data usability (Caughey et al., 2025). In management practice, NSI results can be integrated into unit-level goal management, with regular feedback to nursing teams on trends and benchmarking positions, and intensified monitoring and resource allocation for high-risk units or indicators to enhance the precision and efficiency of improvement efforts (Tevik et al., 2023).
International Journal of Clinical Case Reports, 2026, Vol.16, No.1, 66-83 http://medscipublisher.com/index.php/ijccr 75 5.2 Nursing interventions and preventive measures targeting major adverse events NSI-based analyses help delineate the most common and modifiable adverse event profiles in older patients and guide the implementation of stratified, individualized prevention strategies. Evidence indicates that key nursing-sensitive issues requiring focused attention in older populations include infections, pressure injuries, bladder overdistension, malnutrition, delirium, falls, and medication-related harm (Järbrink et al., 2025; Koehl, 2023). Using falls as an example, nursing interventions should emphasize dynamic assessment at admission and throughout hospitalization, optimization of environmental safety and care coordination, appropriate use of assistive devices, and enhanced monitoring of medication-related risks. Concurrently, patient and family education and caregiver guidance should be strengthened to improve risk recognition, ensuring that process measures are traceable and auditable. In long-term care settings, multifactorial fall prevention programs-including exercise and balance training, environmental modification, medication review (especially psychoactive medications), management of orthostatic hypotension, and foot and footwear assessment-are recommended to reduce fall and fracture risk. However, studies also indicate that without deeper organizational transformation, quantifiable effects may be limited, underscoring the importance of using NSIs such as fall rates as feedback triggers to iteratively refine interventions. Pressure injury prevention should be guided by outcome indicators such as pressure injury incidence and the proportion of newly acquired pressure injuries, and linked with process indicators including completion of skin risk assessments, adherence to repositioning schedules, and utilization of pressure-relieving devices to form executable nursing care pathways. Research shows that nursing-sensitive problems such as pressure injuries, malnutrition, and infections are not uncommon among older trauma patients, highlighting the central role of systematic risk assessment, early mobilization, skin care, elimination management, and nutritional support as core nursing responsibilities (Järbrink et al., 2025). Systematic reviews further indicate that ward-level, multicomponent interventions targeting “mobility-nutrition-cognitive engagement,” when combined with evidence implementation frameworks and adapted to local barriers, can improve mobility and functional outcomes, increase nutritional intake, and reduce delirium-thereby achieving a bundled reduction in multiple geriatric nursing-sensitive complications. Perioperative nursing studies also demonstrate that targeted interventions-such as temperature management, pain and anxiety control, close monitoring, and effective communication-can reduce emergence agitation and related complications in older surgical patients while improving satisfaction, suggesting that strengthening care processes can translate into improved outcomes (Hu and Peng, 2025). Medication safety represents a critical NSI domain requiring focused governance. Reviews and clinical recommendations emphasize that pharmacist- or physician-led medication reviews, geriatric-friendly order sets, and team-based optimization of high-risk prescriptions can reduce the risk of adverse drug events (ADEs); however, effects on “hard outcomes” (e.g., hospitalization and mortality) are inconsistent, highlighting the importance of implementation quality, interprofessional collaboration, and integration with nursing monitoring processes (Koehl, 2023). Building on this foundation, events such as unplanned device removal and catheter-associated infections should be addressed through process optimization and behavioral standardization: strengthening assessment of cognitive and delirium risk and caregiver strategies, standardizing restraint use, refining protocols for catheter fixation and maintenance, and reducing medication errors through double checks, smart medication alerts, and closed-loop medication administration systems to achieve multi-point risk reduction. 5.3 Strengthening nursing staff training and risk management in geriatric care Nursing staff competence and organizational risk management capacity are critical determinants of adverse events in older patients, and systematic development should target vulnerabilities identified through NSIs. Randomized controlled studies show that safety culture training programs in intensive care settings can significantly improve nurses’ safety knowledge, attitudes, practices, and perceptions of the work environment, indicating that the “safety culture-behavior-outcome” chain can be activated through training (Shoukr et al., 2025). Studies in geriatric specialty hospitals further demonstrate that patient safety competence and clinical experience are important predictors of safe nursing behaviors, underscoring the need for targeted training in patient safety competencies and retention of experienced nursing staff. In long-term care facilities, qualitative interview studies suggest that
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