Electronic Thesis and Dissertation Repository


Master of Science


Health and Rehabilitation Sciences


Dr. Aleksandra A. Zecevic


The research on home and community care shows that when safely delivered it can be an efficient way to support elders who require care, potentially preventing a move into costlier institutional care. Learning from system-wide safety breakdowns that occur is necessary to establish appropriate prevention strategies. The purpose of this study was to identify the factors that contributed to adverse events in care-dependent community-dwelling older adults and their caregivers. Using a multiple case study methodology, eight falls were investigated using a comprehensive Systemic Falls Investigative Method. Using within case and across case analyses, a total of 280 contributing factors were identified, and grouped in four distinct themes of safety deficiencies: Everyday living has become risky, Limitations with supervision, Disconnects within the system, and Poor fall risk identification and follow-up. This study provides insights into how and why adverse events occur in home and community care, allowing for targeted systemic improvements.