Care Home Safety Incidents and Safeguarding Reports Relating to Hospital to Care Home Transitions: A Retrospective Content Analysis.

The findings highlight potentially high levels of underreporting. The most common safety incidents reported were pressure damage, medication errors, and premature discharge. Many active failings causing numerous staff actions were identified emphasizing the cost to patients and services. Additionally, latent conditions (failings) were not emphasized; similarly, evidence of learning from safety incidents was not addressed.