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Adverse events in patients in home healthcare: A retrospective record review using trigger tool methodology
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2018 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 1, article id e019267Article in journal (Refereed) Published
Abstract [en]

Objective Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare. Design A study using retrospective record review and trigger tool methodology. Setting and methods Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 predefined triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed. Primary and secondary outcome measures The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs. Results The patients were aged 20-79 years, 280 men and 320 women. The review teams identified 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers. Conclusions AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies.

Place, publisher, year, edition, pages
BMJ Publishing Group , 2018. Vol. 8, no 1, article id e019267
Keywords [en]
home health care, patient harm, patient safety, quality in health care, trigger tool, adult, adverse outcome, aged, decubitus, falling, female, healthcare associated infection, home care, hospital care, human, incidence, major clinical study, male, methodology, outpatient care, retrospective study, Review, social care, Sweden
National Category
Social and Clinical Pharmacy
Identifiers
URN: urn:nbn:se:kth:diva-227104DOI: 10.1136/bmjopen-2017-019267ISI: 000431743500241Scopus ID: 2-s2.0-85040600022OAI: oai:DiVA.org:kth-227104DiVA, id: diva2:1205917
Funder
Medical Research Council of Southeast Sweden (FORSS)
Note

QC 20180515

Available from: 2018-05-15 Created: 2018-05-15 Last updated: 2018-11-12Bibliographically approved
In thesis
1. Exploring patient safety in home healthcare: a resilience engineering approach
Open this publication in new window or tab >>Exploring patient safety in home healthcare: a resilience engineering approach
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of the thesis is to increase knowledge and understanding of patient safety in home healthcare. This thesis has an explorative mixed-methods design, with both qualitative (Papers І and ІІ) and quantitative (Papers ІІІ, ІV and V) methods. Data for Papers І and ІІ were collected at three specialised home healthcare units. The aim for Paper І was to explore patient safety in home healthcare from the multidisciplinary teams and clinical managers’ perspective. Data collection for the study was done through sevenindividual and nine focus group interviews, a total of 51 participants, and analysed with qualitative content analysis. The aim of Paper ІІ was to explore the medication management process. The data collection was done by observing the medication management process for 27 days, 9 days per unit, and through interviews with the healthcare professionals who had been observed.Data was collected in iterative phasesand analysed with grounded theory.The aim of Paper ІІІ was to develop a trigger tool for structured retrospective record review to identify adverse events and no-harm incidents and their preventability that affect adult patients admitted into home healthcare. Another aim was to describe how the development was conducted. During the development, the trigger tool was tested twice, using 60 and 600 records, respectively, from ten different organisations from nine different regions across Sweden. The same 600 randomised home healthcare records were usedfor Papers ІV and V. The aim of Paper ІV was to explore the incidence, types and preventability of adverse events using the trigger tool. For Paper V the aim was to explore cumulative incidence, preventability, types and potential contributing causes of no-harm incidents using the trigger tool. Studies ІІІ, ІV and V were analysed with descriptive statistics.The results showed that the clinical managers and the multidisciplinary teams considered patient safety as associated with their common mind-set of safe care, based on a well-established care ideology. This mindset included the establishment of a trustworthy relationship with patients and relatives. At the same time, provision of care in a home was characterised by weighing valuesagainst each other, between risks and patients’ and relatives’ autonomy and wishes. Other typical contradictory valueswere between collecting measurements for different quality registers (directives from policy-makers as a measure of vquality and safety), or taking time for patient needs. Strategies and behaviours, such as not following routines, to get around problematic processes were the result of conflicting goals that either promoted or prevented patient safety (Papers І and ІІ). Results from Study ІІІ showed that the empirically tested triggers identified more triggers compared to several other studies and thus formed a rich material for validation. More than a third of the patients in home healthcare were affected by adverse events (37.7%), most of which were deemed preventable (71.6%). Most adverse events (69.1%) were temporary and led to that the patient required extra healthcare visits or led to a prolonged period of healthcare. The most common adverse events were “healthcare-associated infections, falls and pressure ulcers (Study ІV). Almost every third patient (29.5%) was affected by a no-harm incident, one-fifth of which were deemed preventable (21.2%). The most common types of no-harm incidents were “fall without harm,” “deficiencies in medication management,” and “moderate pain”. “Deficiencies in medication management” were deemed to have a preventability rate (98.4%)twice as high as “fall without harm” (40.9%)and “moderate pain” (50.0%). The most common potential contributing cause of “fall without harm” was “deficienciesin nursing care, i.e., delayed, erroneous, omitted or incomplete care”. For “deficiencies in medication management” and “moderate pain” the most common contributing cause was “delayed, erroneous, omitted or incomplete treatment”. Of the total number of no-harm incidents, the most common contributing causes were “deficiencies in nursing care, treatment or diagnosis” and “deficiencies in communication, information or collaboration” (PaperV).The conclusion is that patient safety is generally strengthened by the fact that clinical managers and multidisciplinary teams have a common approach to safety built on an internationally and national well-established care ideology, whichforms a “dyad” with safe care. In home healthcare, patient safety is formed by the team creating a trustworthy relationship with patients and their families and involving them as partners in their own care. Additionally, the trigger tool and associated manual adapted for home healthcare may be a valid method for identifying cumulative incidence, types, preventability and contributing causes for adverse events and no-harm incidents. Such patient safety knowledge canbe used to develop valid process indicators for systemic failures, as well as outcome indicators for structured evaluation and lead to proactive patient safety work in home healthcare

Abstract [sv]

viiatt inte följa rutiner, för att komma runt problematiska processer var ett resultat av motstridiga värdensom antingen främjade eller hindrade patientsäker vård (studie І och ІІ). Resultat från studie ІІІ visade att de empiriskt testade markörerna identifierades fler gånger jämfört med flera andra studier och utgjorde därmed ett rikt material för validering. Över en tredjedel av patienterna i hemsjukvården drabbades av skador (37.7%) varav de flesta bedömdes vara undvikbara, det vill säga vårdskador (71.6%). De flesta skador (69.1%) var temporära och ledde till att patienten fick göra extra besöka i öppenvård eller akutmottagningeller ledde till förlängd sjukvårdsperiod. De vanligaste skadorna var ”vårdrelaterade infektioner, ”fall” och ”trycksår” (studie ІV). Nästan var tredje patient (29.5%) drabbades av tillbud varav en femtedel bedömdes vara undvikbara (21.2%). De vanligaste typerna av tillbud var ”fall utan skada”, ”brister i läkemedelshantering” och ”måttlig smärta”. ”Brister i läkemedelshantering” bedömdes ha dubbelt så hög undvikbarhet (98.4%) som ”fall utan skada”(40.9%)och ”måttlig smärta” (50.0%). Den vanligaste möjliga bidragande orsaken till ”fall utan skada” var ”bristande omvårdnad”, det vill säga att den var ”försenad, felaktig, utebliven eller ofullständig”. För "brister i läkemedelshantering" och "måttlig smärta" var den vanligaste bidragande orsaken "försenad, felaktig, utelämnad eller ofullständig behandling". Av det totala antalet tillbud, var vanligaste möjliga bidragande orsakerna"brister i omvårdnad, behandling eller diagnos" och"brister i kommunikation, information eller samarbete"” (studie V).Slutsatsen är att patientsäkerhet, stärks generellt av att kliniska chefer och multidisciplinära team har ett gemensamt synsätt på säkerhet, som baseras på en internationell och nationell väletablerad vårdideologi, som bildar en "dyad" med säker vård. Patientsäkerhet, i hemsjukvård, bildas av att teamen skapar ett tillitsfulltförhållande med patienter och närstående samt involverar dem som samarbetspartner i sin egen vård. Ytterligareenslutsats är det markörbaserade verktyget med tillhörande manual anpassat för hemsjukvård kan vara en valid metod för att identifiera vårdskador, tillbud och bidragande orsaker. Sådan kunskap inom patientsäkerhetsområdet kan användas för att utveckla giltiga processindikatorer för systemfel, samt resultatindikatorer för strukturerad utvärdering och leder till ett proaktivt patientsäkerhetsarbete inom hemsjukvård.

Place, publisher, year, edition, pages
Stockholm: KTH Royal Institute of Technology, 2018. p. 81
Series
TRITA-CBH-FOU ; 2018:51
Keywords
patient safety, home healthcare
National Category
Medical and Health Sciences
Research subject
Technology and Health
Identifiers
urn:nbn:se:kth:diva-238685 (URN)978-91-7729-992-9 (ISBN)
Public defence
2018-11-29, Sal T1, Hälsovägen 11C, Flemingsberg, 08:30 (Swedish)
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Supervisors
Note

QC 20181118

Available from: 2018-11-12 Created: 2018-11-07 Last updated: 2018-11-12Bibliographically approved

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