Contributing causes to adverse events in home care and potential interventions to reduce their incidence

Abstract

The increasing complexity of home care services, pressures to discharge patients quicker, and the growing vulnerabilities of home care clients all contribute to adverse events in home care. In this article, home care staff in six programs analyzed 27 fall- and medication-related events. Classification of contributing causes indicates that patient and environmental factors were common in fall events, while organization and management factors along with patient, task, team, and individual factors were common in medication-related events. Home care settings create specific challenges in identifying and mitigating risks. Some factors, such as variations in home environments, are difficult to address. However, changing care coordination structures and communication methods could ameliorate other factors, including poor communications among staff and limited team and cross-sector communication and coordination. Ensuring that medication ordering and administration processes are optimized for home environments would also contribute to safer care.

Introduction

Patient safety events are often associated with hospital admissions; however, evidence from reviews of patient records and administrative data indicate that patient safety events can occur in many other settings, including home care. A large study of home care clients in three Canadian provinces found that 4.2% of home care patients experienced an adverse event, defined as “an event that results in unintended harm to the client by an act of commission or omission rather than by the underlying disease or condition of the client”.¹ Other Canadian studies of home care patients have found similar or higher rates of harm.^2
–4

Background

The most common adverse events experienced by home care clients are falls, wound infections, psychological or mental health problems, adverse drug reactions, and pressure ulcers.¹ Clients who experience adverse events often require additional care. Doran and colleagues identified that 5% of home care clients who experienced a fall and more than 3% who had a medication-related event had injuries that required a hospital or emergency department visit and were at greater risk of admission to long-term care or death.⁴ A study of home care clients in Ontario and Winnipeg found that 92% required full assistance with instrumental activities of daily living and nearly 50% of Ontario clients experienced some degree of cognitive impairment.⁵ Not surprisingly, such clients are at increased risk of adverse events.⁶ Moreover, care for home care clients is largely unregulated, often intermittent, and delivered by multiple providers, including personal support workers or aides with limited healthcare education. There are growing numbers of home care clients who are discharged earlier from hospitals, are maintained longer in home environments prior to transfer to other settings, and are receiving increasing numbers of medications and complex treatments. All these factors increase the patient safety risks for home care clients. Thus, information on ways to anticipate and mitigate patient safety risks is needed to address these vulnerabilities.

Most data on the incidence of adverse events in home care provide descriptions of the types and frequencies of these events and the characteristics of clients and caregivers involved. However, these data offer only a limited perspective on the pattern of causes contributing to these patient safety events. Identifying contributing causes and how they interact to trigger an adverse event requires event analysis. Such methods provide a structured approach for identifying the contributing causes for an event and inform strategies to mitigate or prevent reoccurrence of similar events. Event analysis has been widely used in healthcare organizations and offers a more fine-grained assessment of the context and the predisposing and triggering elements that produce patient safety events such as falls, pressure ulcers, or adverse drug events. Results from event analysis help to identify strategies to improve safety, although there are continuing concerns that such analyses are time-consuming and that recommendations from these reviews are often insufficient or poorly implemented.^7,8

Existing literature provides only limited information on the contributing causes to home care adverse events. Masotti and colleagues⁹ identified communication problems as a common issue in these events but found limited studies on interventions to reduce adverse events. A Winnipeg-based study of home care patient charts found that a large number of the identified adverse events were preventable or ameliorable and that fragmentation of home care provision was an issue, noting that “stronger communication and collaboration between home care and other providers might help to reduce the number of events attributed to these providers”.³ A Norwegian study found that home care nurses had a greater focus on the treatment of falls than their prevention, noting that patient autonomy may be seen as more important than patient safety.¹⁰ Finally, two studies on medication safety in home care, one in Switzerland and one in Sweden, found that managing medications can be more difficult in home care than in other settings, and successful efforts require the ability to adapt to fluctuating conditions, institute workarounds, and improve communications with other members of the care team.^11,12

To address this gap in the literature, this article describes the patient safety risks and the contributing causes of a sample of home care adverse events, analyzes the nature of contributing causes for those events, identifies potential counter measures, and assesses how root cause or event analysis techniques can be adapted to analyzing events in home care settings and recommending improvements in home care.

Methods

A three-step approach was used to select and analyze a sample of events, assess the contributing causes, and determine possible counter measures to reduce the incidence and mitigate the impact of these events. Two of the most common types of adverse events in home care, client falls and medication incidents, were selected for detailed analysis. A sample of such events was selected from the incident report databases of home care staff in six different locations in three provinces, Ontario (n = 4), Alberta (n = 1), and Manitoba (n = 1). Six teams were recruited and trained to participate in the analysis of events. Team members had prior experience in quality improvement, patient safety, and/or event analysis and they attended an Incident Analysis one-day training session in the application of the “Concise” of the Canadian Framework for Managing Client Safety Incidents.¹³ Following training, each team selected five client cases from their organizations with evidence of an adverse event related to one of the two identified topic areas. Selected events occurred between January 1, 2011, and March 31, 2012, and met pre-established criteria for an adverse event (see Box 1).

Box 1

Key Definitions

Home care adverse event

An event that results in unintended harm to the client by an act of commission or omission rather than by the underlying disease or condition of the client.¹

Concise incident analysis

A concise incident analysis is consistent with the principles and methodology of a comprehensive incident analysis, but a conscious and deliberate decision has been made to focus primarily on four aspects: the facts, key contributing factors, actions for improvement (if any), and evaluation.¹⁴

After selecting a list of potential cases, a member of the team contacted the client, a family member, home care worker, and case manager to obtain their verbal consents to participate in an individual 60-minute face-to-face interview. Efforts were made to identify cases that represent different scenarios, contributing factors, and client demographics to enhance the likelihood of obtaining a broad representation of events and contributing causes. To ensure analytical continuity and consistency, a single team member was assigned to interview all informants for each case. Informed consent was obtained from each interviewee prior to the interview. The interviewers used the interview guide from the Canadian Framework for Managing Client Safety Incidents (Appendix A included in additional materials) to guide their questioning. A standardized study report form (included as Appendix B in additional materials) was used to capture the detailed information from all interviews for each case and submitted to the researchers at the University of Toronto.

Data from these incidents were reviewed and transcribed on a common format (Appendix B) that identified the nature of the clients, the home care services received, and the nature of the events. Two expert panel sessions, one for falls incidents and one for medication-related incidents, were used to examine the data on these events. Members of the panels (Appendix C included in additional materials) were nominated by the participating teams and were selected to represent a range of roles and expertise. Some individuals served on both panels. Each member received a copy of each case report prior to the panel day. During the daylong meetings, panel members reviewed each case and identified contributing causes, recommendations, unexpected learnings, and surprises. The University of Toronto Health Sciences Research Ethics Board granted ethics approval for the study.

Results

Twenty-seven cases, representing 13 cases with a client fall and 14 cases with a medication-related adverse event occurring in the home care sector, were reviewed. The mean age of the clients involved in these events was 80.4 years, 74.1% were female, and 55.5% lived alone. Comorbidities, a description of the event and outcomes, and the contributing causes are listed in Table 1. (Information for a sample of 10 events is included in this Table. The full Table 1 is available in additional materials). For each adverse event, one or more contributing causes are identified, and these were categorized using the risk analysis framework developed by Vincent and colleagues.⁸

Table 1.
Comorbidities, event description, outcomes, and contributing causes for 10 of 27 cases (falls events = 5 medication events = 5)^a

Case Age (years) Gender Care Management Problems Clinical Context and Patient Factors Specific Contributory Factors General Contributory Factors

F-3 67 F
No grab bars in bathroom

Unable to weight bear following knee surgery

Unwitnessed fall—refused initial transfer to ED

Fractured left ankle diagnosed 24 hours later
Patient factor—unable to weight bear Environment factor—building management does not allow equipment attached to walls

F-6 91 F
Alone in apartment soaking feet in tub

Did not have easy access to call button

Unwitnessed fall into bath and unable to pull herself out
Patient factor—slipped into tub and remained there until morning Environment factor—no way to call for help

F-9 77 F
Uses 4-wheeled walker and/or cane outside of apartment but will not use it inside—prefers to “wall or furniture walk”

Prepares her own medication despite dementia

Unwitnessed fall—did not notify caregivers for 5 days. Taken to primary care and diagnosed with compression fracture of spine

Competent clients can make their own decisions

Carpet has contributed to falls in the past
Patient factor—refuses to use walking aids in apartment Environment factor—consideration to removing carpet from apartment

F-10 85 F
Family believes they can manage the mother’s care on their own

Son witnessed fall but unable to get to her

Client fell into bookcase and lost consciousness

Client is severely cognitively impaired, restless, and requires bilateral support
Patient factor—client severely cognitively impaired and non-verbal and acts independently Patient factor—requires constant supervision within reach of caregiver 24/7
Team factor—concern for family caregiver burnout
Organizational and management factor—at maximum amount of home care support

F-13 74 F
Husband believes his wife’s weakness and fatigue, kidney function, and mild mental impairment are all contributing factors to fall

Consistent complement of workers provides care

Complex medical history and a history of frequent falls

Unwitnessed fall “legs just gave way” when walking across apartment from bathroom to bedroom using her 4 wheeled walker

Significant clutter in home

X-rays negative but in hospital x 10 days for treatment of cellulitis and newly diagnosed chronic renal failure
Patient factor—newly diagnosed chronic renal failure—no new falls since starting dialysis (4 months) Environment factor—clutter
Team factor—client required physical assessment by primary care physician

M-1 93 F
Incorrect packaging technique used by community pharmacist resulting in client overdose

LPN delegated responsibility for medication to uncertified HCA

93 year-old legally blind Alzheimer client unable to decipher that once-daily medication was placed in every blister in a four dose per day blister pack
Individual task factor—healthcare aid lacked skills and certification for medication delivery
Patient factor—elderly client legally blind Task factor—community pharmacist placed client’s once-daily medication in every blister of a four dose per day blister pack. Seven-day blister pack contained 1 month’s supply of medication

M-2 67 M
Client with impaired memory discharged home with Home parenteral therapy (PICC line)

Home care agreed to deliver his daily IV antibiotics when there to do his foot dressing but w/e nurse departed before completion of infusion and client left the PICC line open to air

Osteomyelitis and multiple comorbidities including depression, chronic alcoholism, hepatosplenomegaly, DVT, and acute renal failure

PICC line open to air places client at high risk of septicemia or endocarditis

PICC line removed and antibiotics delivered in clinic
Individual factor—home care nurse showed poor judgment leaving patient to complete the IV infusion and reconnect PICC line
Patient factor—client incompetent for managing IV medication Organizational and management factor—review of provincial policies and procedures for home parenteral therapy
Organizational and management factor—review home Care Medication Risk Assessment for IV medications

M-6 85 F
Two missed doses of antibiotics due to home care service assuming nurse received assignment despite never confirming back either verbally or electronically

Daughter had to coordinate home care nurse visits to LTC

LTC facility did not have a nurse on staff who could deliver the IV medication

Client being discharged from acute care back to long-term care and home care was to deliver the IV antibiotics

Daughter not notified of mother’s transfer to LTC
Team factor—multiple individuals involved in intersectoral communication Organizational and management factor—no RN on staff to deliver IV medication
Organizational and management factor—require a reliable system for assigning and confirming case assignment

M-10 97 F
Long-term family doctor retired and new family doctor does not do home visits

New family doctor was not responsive to calls from community pharmacists regarding need for hypotension medication assessment

Being managed by multiple physicians—cardiologist, family doctor, walk-in clinic, and ED—poor inter-MD communication and misunderstanding of who was responsible for specific care management

Client fiercely independent

97 year-old client was cared for by daughter who recently died leaving the client with no one to take her to the family doctor

Client is legally blind. Client has difficulty swallowing pills so nurse crushes medications which renders some inactive and others that can’t be crushed she can’t swallow, eg, iron and stool softener
Patient factor—lack of client advocacy and support
Patient factor—client chooses to live alone Team factors—multiple organizations and physicians delivering care with a lack of communication coordination
Organizational and management factor—no mandatory medical reconciliation post hospital discharge

M-11 98 F
Mixed antibiotics with Tylenol

Resolved through Pharmacist’s home visit and strategic placement of medications in room, ie, PRN meds in bag on door

Legally blind 98 years old

Pharmacist and family physician both make house calls
Patient factor—legally blind unable to differentiate medications Organizational and management factors—care of the medically complex elders requires a more comprehensive approach such as regular geriatric nurse home visits for clients over 70 years old to promote healthy aging in their own homes

^a Analysed using the Vincent Framework of Risk Management.

Abbreviations: ED, Emergency Department; DVT, Deep Vein Thrombosis; LTC, Long Term Care, HCA, Health Care Aide.

For the falls events, the most commonly cited factors contributing to the event were patient related (13 cases). These factors often increase the vulnerability of clients; for example, many events occurred in clients with established prior histories of falls. Environmental factors contributed to eight cases, over half of the falls events. No two homes are alike, and this variability in home environments coupled with the fact that clients often prefer to maintain a familiar environment rather than removing throw rugs or other potential risks increases the likelihood of a fall. Task factors (three cases), organizational and management factors (three cases), team factors (two cases), and individual factors (two cases) were less common among clients experiencing a fall. However, other factors, notably the limited communication between providers, coupled with poor documentation that contributed to inconsistent and inaccurate messaging between providers were also contributing factors. Organizational and management factors also influenced the propensity for falls. For example, the lack of continuity between home care providers and the lack of standard operating procedures for fall risk assessments contributed to a failure to effectively monitor clients who were vulnerable.

The categories of contributing factors most frequently associated with medication events were organizational and management factors (eight cases), patient factors (seven cases), task factors (six cases), team factors (five cases), individual factors (four cases), and work environment factors (two cases). In these cases, there were no cases where environmental factors were judged as contributing causes. In these medication incidents, the frequent absence of standardized communications between team members led to failures to inform providers about changes in diagnoses, treatments, and care requirements. For example, a primary care physician, who had recently taken on an elderly client, assumed that the client’s cardiologist was managing her antihypertensive medication while the home care case manager believed that one of these two physicians would be responsible for monitoring medications. But, in fact, neither of these physicians was managing the client’s medications. Work environment factors such as variations in medication packaging that increased the possibility of client errors in dosage were also observed in many incidents. In some cases, these errors were compounded by the failure to alter the packaging to make the daily doses visible. And the client’s home environment sometimes contributed as well. For example, one client stored her medications in the same cupboard as her spouse’s medications, creating opportunities for selecting and taking the wrong medications. Poor communications and inconsistent coordination are frequent team and management factors contributing to medication events. The organization of home care services, which in some provinces are delivered by a range of agencies with different managers, variable documentation processes, and limited communications across agencies, makes effective communication and coordination difficult.

Several themes identified from the detailed case analyses and discussed during the two 1-day expert panel meetings apply to both falls and medication-related adverse events. These factors point toward potential recommendations for improving care delivery to enhance the safety of clients. In many falls or medication incidents, these events arose as a result of care being inconsistently planned and delivered in home care, without an integrated, interdisciplinary healthcare team to ensure continuity of care delivery and care coordination across healthcare sectors. Poor standardization of care processes, packaging, and equipment was also identified as placing the home care client at risk of harm, as does the dearth of adequate medication review for home care clients, particularly those at highest risk due to age and limited cognitive function. One additional factor, the ability of clients and their families to act as independent decision-makers, which is often seen as a strength in home care, also creates potential risks and is very difficult to mediate.

Members of the expert panel also identified potential solutions for mitigating the identified factors that contributed to the fall- and medication-related events. These recommendations are identified in Table 2.

Table 2.
Expert panel recommendations for reducing the risk of harm related to falls and medications events

#Item Falls Events

1 Obtain risk assessment for falls and recommend regional standardization of policy and guidelines for use

2 Improve equipment adaptation and availability of technology

3 Identify why the user equipment needs not being met, including market gaps, existing design not “user-centred,” case managers require education regarding the “human factors approach” to help improve their procurement decisions, issues related to user needs, that is, physical, mental, social, cosmetic, environmental, and users not consulted or needs assessment not completed

4 Recognize the limitations of access to innovations due to cost and knowledge

5 Provide a true “inter-disciplinary team” with training and role definitions. Including RN, MD, RD, OT, PT, SW, Rec therapist, pharmacy, case manager, PSW, HCA, HSW, EMS, and so on

6 Improve consistency of service providers, team messaging, client assessment, and provider education.

7 Understand risks and their mitigation in home care including multiple specialists, polypharmacy, over-the-counter herbals contribution to falls

8 Decrease fragmentation of communication between team members and across the care continuum—consider implementing a common chart across the care continuum

9 Define criteria for a review

10 Improve equity of access to resources regardless of geography

11 Offer flexibility in provider service to meet client-specific needs

12 Standardize operating procedures including for data collection, time frames, criteria for triggering reviews, standardized tools, follow-up/case conference/case review (every 3-6 months), transition processes, and consults with specialists, for example, geriatrician

13 Provide expanded access to case manager—24/7

14 Increase medical input into risk assessment and plan

15 Plan for how to support the client/family as independent decision-makers

16 Care worker interaction with client/family to ensure a culture of respect and professionalism

17 Evaluate and address issues related to nutrition and depression

18 Provide the client tips on how to fall, how to get up, and have a cell phone or a telephone in every room

19 Recognize that the client may limit the information they share due to anticipated repercussions

20 Identify and overcome barriers to timely access and cost of necessary tools/supports for clients and family

21 Advocate for environmental improvements

22 Ensure client assessments contain key and accurate information including a fall history that is collected before the next fall has occurred. Include family members in the initial assessment

23 Care for complex clients needs to include a frank and open dialogue with client and most influential family members about the risks, eg, self-management, and what can be accomplished in the home, realistic expectations, the importance of advanced planning rather than reacting balanced with the client’s right to live at risk. Refer to “How to support and participate in difficult conversations” from Toronto Central CCAC. Recognize that some clients do better in an environment with others, eg, lodge, seniors residence, LTC

24 Montreal Cognitive Assessment (MOCA) is recommended as the most sensitive tool for assessing dementia at the earliest stage and is available in the public domain.

Medication-related events

1 Standardize medication delivery processes, medication packaging—considering client needs, cost, and consistency, management of high-risk medications, use of drug nomenclature, limit the number of approved pharmacies and protocols for at-risk patient populations

2 Integrate between acute care and community a standardized discharge planning process emphasizing closing feedback loops

3 Have a single point of contact for the client emphasizing the importance of human contact over technology, that is, case manager as the case quarterback and 24/7 hotline for support

4 Define the process for escalation of care

5 Ensure patients and families have a clear role in medication management and are empowered and informed

6 Assessment of capability in home setting with regular reassessment

7 Require understanding of difference between medication management vs medication reconciliation

8 Clear identification of appropriate translator with contact information

9 Continuity of providers can increase safety, whereas changing providers can lead to catching errors

10 Provide tools to assist client in being autonomous

11 Provide visual tools to prevent tampering (ie, a photo of how an intact PICC line should appear)

12 Improve integration with community pharmacist

13 Improve the use of technology to support communication

14 Investigate professional accountability for PSW giving meds

15 Evaluate the client’s cognitive level, language preference, and health and technology literacy

16 Changes to medications to be described to client in clear language by pharmacist

17 Encourage health ministries to provide financial support for pharmacy to be reimbursed for medication counseling/home visit

18 Encourage health ministries to support involvement of independent practitioners (ie, physicians, community pharmacist) and integration with home care

19 Clearly define the accountability and responsibility of caregivers for client outcomes

20 Improve documentation of information related to issues and action taken

21 Caregivers to improve their method for closing the communication loop

22 Minimize hand-offs to reduce the risk of miscommunication and error

23 Develop a method for accessing resources or experts to respond to questions and escalate concerns

24 Provide medications in ready-to-administer form

25 Prepare and have available timelines for medication dispensing and dose changes

26 Develop a checklist for medication reconciliation and accountability for completion

27 Tool to post medication information for client to easily see and access

Abbreviations: PSW, Personal Support Worker; HCA, Health Care Aide; HSW, Home Service Worker; EMS, Emergency Medical Services; CCAC, Community Care Access Centre, LTC, Long Term Care, PSW, Personal Support Worker.

An umbrella recommendation that applied across most themes was to assign a case manager to each home care client and give them the necessary authority and responsibility to allow them to act as “case quarterback” for care delivery, serving as the leader for an interdisciplinary and, where needed, cross-sector team with clear role definitions. These individuals would be responsible for ensuring consistency of care delivery, oversee staff continuity, and establish processes and policies for a reliable communication pathway including expanded mobile access to a case manager 24/7. The “case quarterback” would be required to assess that staff selected to deliver care have the appropriate skills and education required for the task. They would also be responsible for interdisciplinary and inter-sector liaising and ensure that all new information from the client interface is delivered to all decision-makers as required. In addition, the “case quarterback” would facilitate open dialogue between providers, the client, their family, and caregivers to determine and clarify care expectations. Although the current structure and funding of home care creates barriers to such a role, this individual could help to reduce the current communication and coordination of care gaps that now contribute to adverse events.

Other expert panel recommendations included developing policies regarding the process and timing for routine risk assessments, particularly for frail elderly patients. Panel members suggested that these policies and processes should include a strategy for ensuring that any changes in the results of the risk assessment are flagged and followed up. Procedures are also needed to ensure that staff are educated on new strategies, policies, and procedures, and the panel believed that all staff would benefit from human factors training to enable them to identify and reduce risks in the home setting. In addition, the panel recommended developing a common chart accessible by all providers and caregivers. The development and consistent application of standard operating procedures for all cases on issues such as the timing of assessments and reviews, processes for adapting equipment and tools, and identifying the need for external consultation (eg, to geriatricians) and for assessment tools (eg, Montreal Cognitive Assessment [MOCA]) would contribute to safer care. The expert panel reinforced the importance of engaging the client and their family in all care-related decisions, noting that this requires frank and open dialogues between the healthcare team members and the client.

Discussion

The increasing complexity of home care services and the growing number of clients with multiple chronic diseases and limited mobility and cognitive functioning have contributed to the growing vulnerability of home care clients to adverse events. Assessment of the events experienced by clients and by home care staff in six home care programs in three provinces using the Concise Incident Analysis Tool identified a number of common themes for clients experiencing medication-related and fall events. Patient and environmental factors were common in fall events, while organization and management factors along with patient, task, team, and individual factors were common in medication-related events. Home care settings create specific challenges in identifying and mitigating risks. Some factors, such as the variations in home environments, are difficult to address. Yet changing care coordination structures and communication methods could ameliorate other factors, including poor communications among staff and limited team and cross-sector communication and coordination. Ensuring that medication ordering and administration processes are optimized for home environments would also contribute to safer care.

This study deliberately chose events from multiple settings to try to identify a broad range of events in two common categories, falls and medication-related incidents. The number of events analyzed was small and not intended to be representative of the full range of events experienced in home care. The goal of this study was not to develop a full typology of events and contributing causes or to assess the prevalence of such incidents. Instead the study aimed to test the use of the Concise Incident Analysis Tool to see whether home care staff and experts could use the data from this tool to identify potential interventions to reduce adverse events and ameliorate the care environments in which these events occur.

This review of patient safety incidents carried out on a small scale in this study suggests there are effective methods for continuing review of potential risks in home care. The participation of teams from different provinces and programs helped to ensure a variety of cases and to pinpoint common issues across these programs, which have different structures and staffing. These methods could be adapted for continuing use as a risk management strategy in home care programs in Canada and elsewhere and augment current risk management and quality improvement initiatives in home care programs.

Conclusions

Patient safety in home care is a growing concern. The increasing vulnerability of clients, the growing complexity of treatments, and the limited coordination and communication among care providers and agencies have contributed to increased risks. The use of cause analysis tools, such as the Concise Incident Analysis Tool to review home care incidents, offers a feasible approach for providing information that informs improvements in care for home care clients.

Case	Age (years)	Gender	Care Management Problems	Clinical Context and Patient Factors	Specific Contributory Factors	General Contributory Factors
F-3	67	F	No grab bars in bathroom	Unable to weight bear following knee surgery Unwitnessed fall—refused initial transfer to ED Fractured left ankle diagnosed 24 hours later	Patient factor—unable to weight bear	Environment factor—building management does not allow equipment attached to walls
F-6	91	F	Alone in apartment soaking feet in tub Did not have easy access to call button	Unwitnessed fall into bath and unable to pull herself out	Patient factor—slipped into tub and remained there until morning	Environment factor—no way to call for help
F-9	77	F	Uses 4-wheeled walker and/or cane outside of apartment but will not use it inside—prefers to “wall or furniture walk” Prepares her own medication despite dementia	Unwitnessed fall—did not notify caregivers for 5 days. Taken to primary care and diagnosed with compression fracture of spine Competent clients can make their own decisions Carpet has contributed to falls in the past	Patient factor—refuses to use walking aids in apartment	Environment factor—consideration to removing carpet from apartment
F-10	85	F	Family believes they can manage the mother’s care on their own	Son witnessed fall but unable to get to her Client fell into bookcase and lost consciousness Client is severely cognitively impaired, restless, and requires bilateral support	Patient factor—client severely cognitively impaired and non-verbal and acts independently	Patient factor—requires constant supervision within reach of caregiver 24/7 Team factor—concern for family caregiver burnout Organizational and management factor—at maximum amount of home care support
F-13	74	F	Husband believes his wife’s weakness and fatigue, kidney function, and mild mental impairment are all contributing factors to fall Consistent complement of workers provides care	Complex medical history and a history of frequent falls Unwitnessed fall “legs just gave way” when walking across apartment from bathroom to bedroom using her 4 wheeled walker Significant clutter in home X-rays negative but in hospital x 10 days for treatment of cellulitis and newly diagnosed chronic renal failure	Patient factor—newly diagnosed chronic renal failure—no new falls since starting dialysis (4 months)	Environment factor—clutter Team factor—client required physical assessment by primary care physician
M-1	93	F	Incorrect packaging technique used by community pharmacist resulting in client overdose LPN delegated responsibility for medication to uncertified HCA	93 year-old legally blind Alzheimer client unable to decipher that once-daily medication was placed in every blister in a four dose per day blister pack	Individual task factor—healthcare aid lacked skills and certification for medication delivery Patient factor—elderly client legally blind	Task factor—community pharmacist placed client’s once-daily medication in every blister of a four dose per day blister pack. Seven-day blister pack contained 1 month’s supply of medication
M-2	67	M	Client with impaired memory discharged home with Home parenteral therapy (PICC line) Home care agreed to deliver his daily IV antibiotics when there to do his foot dressing but w/e nurse departed before completion of infusion and client left the PICC line open to air	Osteomyelitis and multiple comorbidities including depression, chronic alcoholism, hepatosplenomegaly, DVT, and acute renal failure PICC line open to air places client at high risk of septicemia or endocarditis PICC line removed and antibiotics delivered in clinic	Individual factor—home care nurse showed poor judgment leaving patient to complete the IV infusion and reconnect PICC line Patient factor—client incompetent for managing IV medication	Organizational and management factor—review of provincial policies and procedures for home parenteral therapy Organizational and management factor—review home Care Medication Risk Assessment for IV medications
M-6	85	F	Two missed doses of antibiotics due to home care service assuming nurse received assignment despite never confirming back either verbally or electronically Daughter had to coordinate home care nurse visits to LTC LTC facility did not have a nurse on staff who could deliver the IV medication	Client being discharged from acute care back to long-term care and home care was to deliver the IV antibiotics Daughter not notified of mother’s transfer to LTC	Team factor—multiple individuals involved in intersectoral communication	Organizational and management factor—no RN on staff to deliver IV medication Organizational and management factor—require a reliable system for assigning and confirming case assignment
M-10	97	F	Long-term family doctor retired and new family doctor does not do home visits New family doctor was not responsive to calls from community pharmacists regarding need for hypotension medication assessment Being managed by multiple physicians—cardiologist, family doctor, walk-in clinic, and ED—poor inter-MD communication and misunderstanding of who was responsible for specific care management Client fiercely independent	97 year-old client was cared for by daughter who recently died leaving the client with no one to take her to the family doctor Client is legally blind. Client has difficulty swallowing pills so nurse crushes medications which renders some inactive and others that can’t be crushed she can’t swallow, eg, iron and stool softener	Patient factor—lack of client advocacy and support Patient factor—client chooses to live alone	Team factors—multiple organizations and physicians delivering care with a lack of communication coordination Organizational and management factor—no mandatory medical reconciliation post hospital discharge
M-11	98	F	Mixed antibiotics with Tylenol Resolved through Pharmacist’s home visit and strategic placement of medications in room, ie, PRN meds in bag on door	Legally blind 98 years old Pharmacist and family physician both make house calls	Patient factor—legally blind unable to differentiate medications	Organizational and management factors—care of the medically complex elders requires a more comprehensive approach such as regular geriatric nurse home visits for clients over 70 years old to promote healthy aging in their own homes

#Item	Falls Events
1	Obtain risk assessment for falls and recommend regional standardization of policy and guidelines for use
2	Improve equipment adaptation and availability of technology
3	Identify why the user equipment needs not being met, including market gaps, existing design not “user-centred,” case managers require education regarding the “human factors approach” to help improve their procurement decisions, issues related to user needs, that is, physical, mental, social, cosmetic, environmental, and users not consulted or needs assessment not completed
4	Recognize the limitations of access to innovations due to cost and knowledge
5	Provide a true “inter-disciplinary team” with training and role definitions. Including RN, MD, RD, OT, PT, SW, Rec therapist, pharmacy, case manager, PSW, HCA, HSW, EMS, and so on
6	Improve consistency of service providers, team messaging, client assessment, and provider education.
7	Understand risks and their mitigation in home care including multiple specialists, polypharmacy, over-the-counter herbals contribution to falls
8	Decrease fragmentation of communication between team members and across the care continuum—consider implementing a common chart across the care continuum
9	Define criteria for a review
10	Improve equity of access to resources regardless of geography
11	Offer flexibility in provider service to meet client-specific needs
12	Standardize operating procedures including for data collection, time frames, criteria for triggering reviews, standardized tools, follow-up/case conference/case review (every 3-6 months), transition processes, and consults with specialists, for example, geriatrician
13	Provide expanded access to case manager—24/7
14	Increase medical input into risk assessment and plan
15	Plan for how to support the client/family as independent decision-makers
16	Care worker interaction with client/family to ensure a culture of respect and professionalism
17	Evaluate and address issues related to nutrition and depression
18	Provide the client tips on how to fall, how to get up, and have a cell phone or a telephone in every room
19	Recognize that the client may limit the information they share due to anticipated repercussions
20	Identify and overcome barriers to timely access and cost of necessary tools/supports for clients and family
21	Advocate for environmental improvements
22	Ensure client assessments contain key and accurate information including a fall history that is collected before the next fall has occurred. Include family members in the initial assessment
23	Care for complex clients needs to include a frank and open dialogue with client and most influential family members about the risks, eg, self-management, and what can be accomplished in the home, realistic expectations, the importance of advanced planning rather than reacting balanced with the client’s right to live at risk. Refer to “How to support and participate in difficult conversations” from Toronto Central CCAC. Recognize that some clients do better in an environment with others, eg, lodge, seniors residence, LTC
24	Montreal Cognitive Assessment (MOCA) is recommended as the most sensitive tool for assessing dementia at the earliest stage and is available in the public domain.
	Medication-related events
1	Standardize medication delivery processes, medication packaging—considering client needs, cost, and consistency, management of high-risk medications, use of drug nomenclature, limit the number of approved pharmacies and protocols for at-risk patient populations
2	Integrate between acute care and community a standardized discharge planning process emphasizing closing feedback loops
3	Have a single point of contact for the client emphasizing the importance of human contact over technology, that is, case manager as the case quarterback and 24/7 hotline for support
4	Define the process for escalation of care
5	Ensure patients and families have a clear role in medication management and are empowered and informed
6	Assessment of capability in home setting with regular reassessment
7	Require understanding of difference between medication management vs medication reconciliation
8	Clear identification of appropriate translator with contact information
9	Continuity of providers can increase safety, whereas changing providers can lead to catching errors
10	Provide tools to assist client in being autonomous
11	Provide visual tools to prevent tampering (ie, a photo of how an intact PICC line should appear)
12	Improve integration with community pharmacist
13	Improve the use of technology to support communication
14	Investigate professional accountability for PSW giving meds
15	Evaluate the client’s cognitive level, language preference, and health and technology literacy
16	Changes to medications to be described to client in clear language by pharmacist
17	Encourage health ministries to provide financial support for pharmacy to be reimbursed for medication counseling/home visit
18	Encourage health ministries to support involvement of independent practitioners (ie, physicians, community pharmacist) and integration with home care
19	Clearly define the accountability and responsibility of caregivers for client outcomes
20	Improve documentation of information related to issues and action taken
21	Caregivers to improve their method for closing the communication loop
22	Minimize hand-offs to reduce the risk of miscommunication and error
23	Develop a method for accessing resources or experts to respond to questions and escalate concerns
24	Provide medications in ready-to-administer form
25	Prepare and have available timelines for medication dispensing and dose changes
26	Develop a checklist for medication reconciliation and accountability for completion
27	Tool to post medication information for client to easily see and access

Footnotes

Authors’ note

Additional details of study results, including an expanded version of Table 1, the Incident Analysis Guiding Questions used in the review, the Common Format Report Form, and the list of the expert panel members who developed the recommendations can be found at .

Acknowledgments

The authors would also like to acknowledge cash contributions from the Nova Scotia Health Research Foundation and the Ministry of Health and Social Services, Government of Quebec as well in kind contributions from the Canadian Institute for Health Information, Nova Scotia Department of Health, Victorian Order of Nurses (VON) Canada, the Winnipeg Regional Health Authority, and Alberta Health Services. The authors would like to thank Carolyn Hoffman and Paula Beard of Alberta Health Services for facilitating the training session in the use of the Concise Incident Analysis. Carolyn Hoffman, Paula Beard, and James Handyside helped to lead the provincial feedback sessions reviewing the results of the incident reports. The authors thank the expert panel members who reviewed the results of the Concise Incident reviews for falls and medication-related incidents. Their names are listed in Additional Materials. The authors would also like to thank Melissa Griffen and James Handyside for their human factors expertise that contributed to the analysis of the results of the incident reviews.

Funding

The research reporting in this article was funded as part of a larger project, Safety at Home: A Pan-Canadian Homecare Safety Study. Funding for this research was provided by the Canadian Patient Safety Institute, the Canadian Institutes of Health Research, The Change Foundation, and the Canadian Foundation for Healthcare Improvement.

ORCID iD

Regis Blais, PhD

References

Blais

Sears

Doran

. Assessing adverse events among home care clients in three Canadian provinces using chart review. BMJ Qual Saf. 2013;22(12):989–997.

Sears

Baker

Barnsley

Shortt

. The incidence of adverse events among home care patients. Int J Qual Health Care. 2013;25(1):16–28.

Johnson

. Adverse events among Winnipeg home care clients. Healthcare Q. 2004;9. Spec no:127-134.

Doran

Hirdes

Blais

. Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study. BMC Health Serv Res. 2013;13:227.

Mofina

Guthrie

. A comparison of home care quality indicator rates in two Canadian provinces. BMC Health Serv Res. 2014;14(1):37.

Sears

Blais

Spinks

Paré

Baker

. Associations between patient factors and adverse events in the home care setting: a secondary data analysis of two canadian adverse event studies. BMC Health Serv Res. 2017;17(1):400.

Vincent

. Understanding and responding to adverse events. N Engl J Med. 2003;348(11):1051–1056.

Vincent

Taylor-Adams

Chapman

. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000;320(7237):777–781.

Masotti

McColl

Green

. Adverse events experienced by homecare patients: a scoping review of the literature. Int J Qual Health Care. 2010;22(2):115–125.

10.

Berland

Gundersen

Bentsen

. Patient safety and falls: a qualitative study of home care nurses in Norway. Nurs Health Sci. 2012;14(4):452–457.

11.

Meyer-Massetti

Kaiser

Hedinger-Grogg

Luterbacher

Hersberger

. Medication safety in the home care setting: error-prone process steps [in German]. Pflege. 2012;25(4):260–269.

12.

Lindblad

Flink

Ekstedt

. Safe medication management in specialized home healthcare—an observational study. BMC Health Serv Res. 2017;17(1):598.

13.

Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Edmonton, Alberta: Canadian Patient Safety Institute; 2012. Available at: http://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Pages/incidentanalysis.aspx. Accessed July 25, 2018.

14.

Hoffman

Eldridge

Gianci

Goldschmidt

. Concise Incident Analysis: Draft Methodology. Geneva, Switzerland: WHO. 2012.