The majority of patient safety research has focused on adverse events in the hospital setting. This study contributes valuable information by translating hospital-centred patient safety definitions to the home care context and measuring patient safety among home care clients in the Winnipeg Regional Health Authority. The annual incidence of adverse events was 5.5%, which is lower than the rate found in Canadian hospitals but higher than that found in US hospitals. Multiple providers (e.g., home care providers and/or the client, a caregiver, or other provider) were involved in over 45% of the adverse events, suggesting fragmentation of care provision. The home care-specific patient safety definitions may be of use to other Canadian home care organizations seeking to measure adverse events and their causes among their respective populations.

Background: Patient safety is a prominent issue on the Canadian health policy agenda, but most research has focused on adverse events (AEs) in the hospital setting. Little is known about patient safety in the home care setting, where the provision of care and environment in which care is received is less controlled than in the hospital. This study fills two voids in the literature by (1) translating hospitalcentred patient safety definitions and concepts to the home care context, and (2) measuring the annual incidence, type, harm, cause, prevention and improvement of AEs among home care clients in the Winnipeg Regional Health Authority.

Methods: Home care-specific adverse events were defined as "Any harm to the client that negatively affects their overall health and/or functioning and is the result of care actions and/or inactions (from any provider, including home care and other providers, direct service staff, the client, and informal caregivers) rather than the client's underlying condition." This study examines AEs among home care clients caused by any provider, not just home care providers, because home care clients receive care from multiple providers. Adverse events that occurred during 2004 among a random sample of 400 patient charts were reviewed and measured. Seven types of AEs were identified: falls, injuries, skin problems or ulcers, infections, medication-related events, hospitalization, nursing home placement, and death. Trained staff reviewed all charts for which an AE had been identified in the screening process and recorded the details of the AE including the level of harm to client and cause, and whether the AE could have been prevented or its impact lessened (e.g., a different approach could have reduced harm).

Findings: Of the 400 charts screened, 215 clients (53.8%) were identified as having had a potential AE and were therefore subject to full chart review. Of these, 22 clients experienced at least one AE and three clients had multiple events, yielding a total of 26 AEs and an annual incidence rate of 5.5%. The most prevalent types of AEs were injurious falls (12), medication-related events (6), non-injurious falls (4), pressure ulcers (1), and mental harm/injury (1). Chart reviews revealed that 18 of the 26 AEs resulted in temporary harm or injury, one in permanent harm, four in unnecessary hospitalization, and one where the care recipient was placed in a nursing home prematurely. Chart reviews also documented the provider(s) involved in each AE: 50% of AEs were associated with paid home care providers (with the majority attributed to case management issues as opposed to direct service delivery), while informal caregivers, clients themselves and other providers contributed to 42.3%, 30.8%, and 42.3% of AEs, respectively. In 46.2% of AEs, multiple providers were involved. Of the home care-attributable events, 94.5% were classified as preventable or its impact lessened, while only 36.4% of events associated with other providers were rated accordingly. Almost all home care-related AEs were falls, while adverse drug events were most common when other providers were involved.

Conclusions: The annual incidence of home care AEs was 5.5%, which is lower than the incidence of 7.5% found in Canadian hospitals, but higher than US hospital rates of 3%. The prevention and improvement ratings are also higher than those found in post-discharge hospital studies. Home care was a contributing factor in half of all AEs, with multiple providers also involved in a number of events, potentially pointing to a fragmented system of care provision. To improve patient safety in the home care setting, the author suggests a falls prevention program and stronger communication and collaboration between home care and other providers. The home care-specific patient safety definitions developed in this study may be of use to other Canadian home care organizations seeking to measure patient safety among their own clientele.

Reference: Johnson KG. "Adverse Events among Winnipeg Home Care Clients". Healthcare Quarterly, 2006; 9(special issue), 127-134.

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