Adverse events experienced by homecare patients: A scoping review of the literature

International Journal for Quality in Health Care

Volumn 22, Issue 2, 2010, Pages 115-125

  Masotti, Paul ^a   McColl, Mary Ann ^a   Green, Michael ^a  

^a QUEEN S UNIVERSITY   (Canada)

Author keywords

Adverse events; Falls; Home care services; Infections; Medical errors; Patient safety

Indexed keywords

ANTICOAGULANT AGENT; DRUG;

ADVERSE OUTCOME; ARTICLE; BLEEDING; CAREGIVER; CINAHL; COCHRANE LIBRARY; COORDINATION; DIAGNOSTIC ERROR; DRUG HYPERSENSITIVITY; EMBASE; FALLING; GASTROINTESTINAL DISEASE; HEALTH CARE; HEALTH CARE DELIVERY; HEALTH CARE PERSONNEL; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH CARE UTILIZATION; HOME CARE; HUMAN; INTERPERSONAL COMMUNICATION; MEDLINE; PATIENT CARE; PATIENT EDUCATION; PATIENT MONITORING; PATIENT SAFETY; PRIORITY JOURNAL; RISK REDUCTION; TREATMENT FAILURE; URINARY CATHETER; WOUND INFECTION;

ACCIDENTAL FALLS; BACTERIAL INFECTIONS; CANADA; DRUG TOXICITY; HEALTH SERVICES RESEARCH; HOME CARE SERVICES; HUMANS; INCIDENCE; MEDICATION ADHERENCE; PRESSURE ULCER; PREVALENCE; PUBLIC POLICY; SAFETY MANAGEMENT; WOUNDS AND INJURIES;

EID: 77952589701     PISSN: 13534505     EISSN: 14643677     Source Type: Journal    
DOI: 10.1093/intqhc/mzq003     Document Type: Article

References (132)

1. Woodward C, Brown J, Abelson J et al. Measuring consistency of personnel in home care: current challenges and findings [A Shortened Version of the Report Presented at the From Knowledge To Wisdom Conference, Sheraton Centre Hotel, Toronto, Canada, April 21-24, 2002]. Centre for Health Economics and Policy Analysis, 2002. http://www.chepa.org/Portals/0/pdf/02-01update.pdf.
2. McGraw C, Drennan V, Humphrey C. Understanding risk and safety in home health care: the limits of generic frameworks. Qual Prim Care 2008;16:239-48.
3. Lang A, Edwards N, Fleiszer A. Safety in home care: a broadened perspective of patient safety. Int J Qual Health Care 2008;20:130-5.
4. Lang A, Edwards N. Safety in home care: broadening the patient safety agenda to include home care services. Canadian Patient Safety Institute 2006. http://www.patientsafetyinstitute.ca/uploadedFiles/Research/Safety%20in%20Home%20Care%20-%20Apr%202006.pdf.
5. Coyte PC, McKeever P. Home care in Canada: passing the buck. Can J Nurs Res 2001;33:11-25.
6. Richardson B. Implementing home care in Canada: four critical elements. Healthc Pap 2000;1:67-73; discussion.
7. Health Canada. Public home care expenditures in Canada, 1975-76 to 1997-98. Health Canada 1998. http://dsp-psd.pwgsc.gc.ca/Collection/H39-432-1998.pdf.
8. Masotti P, McColl M, Green M. Assessment of Adverse Events in Canadian Home Care: A Scoping Review. Report submitted to the Canadian Institutes of Health Research. Queen's University: Centre for Health Services and Policy Research, 2008. Available at http://chspr.queensu.ca/.
9. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methods 2005;8:19-32.
10. Masotti P, Green M, Shortt SE et al. Adverse events in community care: developing a research agenda. Healthc Q 2007;10:59-65.
11. O'Malley L, Croucher K. Housing and dementia care-a scoping review of the literature. Health Soc Care Community 2005;13:570-7.
12. Leff B, Montalto M. Hospital at home: potential in geriatric healthcare and future challenges to dissemination. Aging Health 2006;2:701-3.
13. Crisler KS, Richard AA. Using case mix and adverse event outcome reports for outcome-based quality monitoring. Home Healthc Nurse 2001;19:613-21.
14. Madigan EA. A description of adverse events in home healthcare. Home Healthc Nurse 2007;25:191-7.
15. Madigan EA, Tullai-McGuinness S. An examination of the most frequent adverse events in home care agencies. Home Healthc Nurse 2004;22:256-62.
16. Johnson KG. Adverse events among Winnipeg Home Care clients. Healthc Q 2006;9: spec no. 127-34.
17. Caplan GA, Ward JA, Brennan NJ et al. Hospital in the home: a randomised controlled trial. Med J Aust 1999;170:156-60.
18. Liu AL, Taylor DM. Adverse events and complications among patients admitted to hospital in the home directly from the emergency department. Emerg Med (Fremantle) 2002;14:400-5.
19. Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention St udy Gr oup. JAMA 1995;274:29-34.
20. Steinmetz D, Berkovits E, Edelstein H et al. Home intravenous antibiotic therapy programme, 1999. J Infect 2001;42:176-80.
21. Moureau N, Poole S, Murdock MA et al. Central venous catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol 2002;13:1009-16.
22. Gorski LA. Central venous access device occlusions: part 2: nonthrombotic causes and treatment. Home Healthc Nurse 2003;21:168-71.
23. Berger L. The effects of positive pressure devices on catheter occlusions. J Vasc Access Devices 2000;5:31-3.
24. Herbst SL, Kaplan LK, McKinnon BT. Vascular access devices: managing occlusions and related complications in home infusion. Infusion 1998;4:1-32.
25. Moureau NL, Zonderman A. Complications of vascular access device terminal tip placement: a case study and review of subsequent legal action. J Assoc Vasc Access 2007;12:33-7.
26. Berg AM, Snell L, Mahle WT. Home inotropic therapy in children. J Heart Lung Transplant 2007;26:453-7.
27. Gorski LA. Central venous access device outcomes in a homecare agency: a 7-year study. J Infus Nurs 2004;27:104-11.
28. Ryder M. Evidence-based practice in the management of vascular access devices for home parenteral nutrition therapy. JPEN J Parenter Enteral Nutr 2006;30:S82-S93.
29. Ireton-Jones C, DeLegge M. Home parenteral nutrition registry: a five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support. Nutrition 2005;21:156-60.
30. Wade BH, Bush SE. Infection control and outpatient parenteral antibiotic therapy. Infect Dis Clin North Am 1998;12:979-94.
31. Buchman AL. Complications of long-term home total parenteral nutrition: their identification, prevention and treatment. Dig Dis Sci 2001;46:1-18.
32. Shirotani N, Iino T, Numata K et al. Complications of central venous catheters in patients on home parenteral nutrition: an analysis of 68 patients over 16 years. Surg Today 2006;36:420-4.
33. Increasing use of devices fuels infections in home care: national infection control efforts lag. Hosp Infect Control 2000;27:1-3.
34. Luehm D, Fauerbach L. Task force studies. Infection rates, surgical site management, & foley catheter infections. Caring 1999;18:30-4.
35. Huisman-de WG, Naber T, Schoonhoven L et al. Problems experienced by patients receiving parenteral nutrition at home: results of an open interview study. JPEN J Parenter Enteral Nutr 2006;30:215-21.
36. Colomb V, Fabeiro M, Dabbas M et al. Central venous catheter-related infections in children on long-term home parenteral nutrition: incidence and risk factors. Clin Nutr 2005;19:355-9.
37. Gambarara M, Ferretti F, Papadatou B et al. Central vein catheter-related complications associated with home parenteral nutrition in children: experience in 41 patients. Nutrition 2001;17:970-1.
38. Hoffman-Terry ML, Fraimow HS, Fox TR et al. Adverse effects of outpatient parenteral antibiotic therapy. Am J Med 1999;106:44-9.
39. de Burgoa LJ, Seidner D, Hamilton C et al. Examination of factors that lead to complications for new home parenteral nutrition patients. J Infus Nurs 2006;29:74-80.
40. Huffam S, Jacups SP, Kittler P et al. Out of hospital treatment of patients with melioidosis using ceftazidime in 24h elastomeric infusors, via peripherally inserted central catheters. Trop Med Int Health 2004;9:715-7.
41. Moreno JM, Valero MA, Gomis P et al. Central venous catheter occlusion in home parenteral nutrition patients. Clin Nutr 1998;17:35-6.
42. de Luis DA, Aller R, de LJ et al. Clinical and biochemical characteristics of patients with home enteral nutrition in an area of Spain. Eur J Clin Nutr 2003;57:612-5.
43. Srinivasan S, Doty SM, White TR et al. Frequency, causes, and outcome of home ventilator failure. Chest 1998;114:1363-7.
44. Simonds AK. Risk management of the home ventilator dependent patient. Thorax 2006;61:369-71.
45. Bruno L, Ahrens J. Examining 'operational failures' to reduce home care errors. Caring 2005;24:34-9.
46. Tucker AL. A case study of operational failure in home healthcare. J Healthc Qual 2004;26:38-43.
47. Baruchin O, Yoffe B, Baruchin AM. Burns in inpatients by simultaneous use of cigarettes and oxygen therapy. Burns 2004;30:836-8.
48. Chang TT, Lipinski CA, Sherman HF. A hazard of home oxygen therapy. J Burn Care Rehabil 2001;22:71-4.
49. How safe are your patients who use oxygen? NPSGs focus on risk of fire: improving oxygen risk assessment included in 2007 goals. Hospital Home Health 2006;23:73-5.
50. MacAdam M. Examining home care in other countries: the policy issues. Home Health Care Manag Pract 2004;16:393-404.
51. Cusick JM. Burn Prevention Forum. J Burn Care Rehabil 2001;22:70-1.
52. Home health: nurse was an employee. Legal Eagle Eye Newsl Nursing Profession 2002;10:8.
53. Abood RR. Legal issues. Products liability in home health care. Home HealthCare Consult 1998;5:21-5.
54. Tammelleo AD. 'Preemie' dies on home health nurse's watch. Nurs Law Regan Rep 2004;44:1.
55. Ing TS, Kohn O. Fire hazards related to the use of dialysis machines. Int J Artif Organs 2005;28:1053.
56. Marrie TJ, Huang JQ. Community-acquired pneumonia in patients receiving home care. J Am Geriatr Soc 2005;53:834-9.
57. Long CO, Anderson C, Greenberg EA et al. Defining and monitoring indwelling catheter-related urinary tract infections. Home Healthc Nurse 2002;20:255-62.
58. Patte R, Drouvot V, Quenon JL et al. Prevalence of hospital-acquired infections in a home care setting. J Hosp Infect 2005;59:148-51.
59. Newman DK. Managing indwelling urethral catheters. Ostomy Wound Manage 1998;44:26-32.
60. Hardyck C, Petrinovich L. Reducing urinary tract infections in catheterized patients. Ostomy Wound Manage 1998;44:36-43.
61. Bucher GM, Szczerba P, Curtin PM. A comprehensive fall prevention program for assessment, interventions, and referral. Home Healthc Nurse 2007;25:174-83.
62. Atkinson WL, Frey D. Integration of a medication management model into outcome-based quality improvement: a pilot program in a rural proprietary home healthcare agency. Home Health Care Serv Q 2005;24:29-45.
63. Root causes: getting to the bottom of medication errors in home care. JCAH Perspect 2004;4:5-6.
64. Temp worker's mistake costs a life and $800,000. J Healthc Risk Manage 2003.
65. Ahrens J, Feldman PH, Frey D. Preventing medication errors in home care. Cent Home Care Policy Res 2002;12:1-6.
66. Meredith S, Feldman PH, Frey D et al. Possible medication errors in home healthcare patients. J Am Geriatr Soc 2001;49:719-24.
67. Fialova D, Topinkova E, Gambassi G et al. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA 2005;293:1348-58.
68. Ahrens J. Combatting medication errors in home health. Caring 2003;22:56-9.
69. Frey D. The medication management model: an effective tool for home health providers. Home Health Care Manage Pract 2003;15:222-30.
70. Golden AG, Preston RA, Barnett SD et al. Inappropriate medication prescribing in homebound older adults. JAm Geriatr Soc 1999;47:948-53.
71. Higher risk of medication errors for seniors: home health bigger challenge: use guidelines specific to elderly, and monitor errors. Hospital Home Health 2002;19:85-8.
72. Sturkey EN, Linker S, Keith DD et al. Improving wound care outcomes in the home setting. J Nurs Care Qual 2005;20:349-55.
73. Foust JB, Naylor MD, Boling PA et al. Opportunities for improving post-hospital home medication management among older adults. Home Health Care Serv Q 2005;24:101-22.
74. Franklin M. Using patient safety science to explore strategies for improving safety in intravenous medication administration. J Vasc Access 2006;11:157-60.
75. Fletcher PC, Hirdes JP. Risk factors for falling among community-based seniors using home care services. J Gerontol A Biol Sci Med Sci 2002;57:M504-M510.
76. Scott VJ, Votova K, Gallagher E. Falls prevention training for community health workers: strategies and actions for independent living (SAIL). J Gerontol Nurs 2006;32:48-56.
77. Taft SH, Pierce CA, Gallo CL. From hospital to home and back again: a study in hospital admissions and deaths for home care patients. Home Health Care Manag Pract 2005;17:467-80.
78. Gallagher B, Corbett E, Freeman L et al. A fall prevention program for the home environment. Home Care Provid 2001;6:157-63.
79. Axelsson J, Elmstahl S. Home care aides in the administration of medication. Int J Qual Health Care 2004;16:237-43.
80. Boling PA. The challenging problem of care transitions in home health care. Caring 2006;25:24-6.
81. Gray SL, Mahoney JE, Blough DK. Adverse drug events in elderly patients receiving home health services following hospital discharge. Ann Pharmacother 1999;33:1147-53.
82. Benson J. Incident reporting: a vital link to organizational performance. Home Healthc Nurse Manag 2000;4:6-10.
83. Bruno L, Ahrens J. Research. The importance of screening for depression in home care patients. Caring 2003;22:54-8.
84. Scharpf TP. Functional status and quality in home health care. Ph.D. thesis. Case Western Reserve University, 2005, 151.
85. Ibrahim IA, Kang E, Dansky KH. Polypharmacy and possible drug-drug interactions among diabetic patients receiving home health care services. Home Health Care Serv Q 2005;24:87-99.
86. Seals AB, Duffy VG. Toward development of a computerbased methodology for evaluating and reducing medication administration errors. Ergonomics 2005;48:1151-68.
87. Cowley EP. Assessing and preventing medication errors in home care. Home Health Care Consult 2000;7:33-40.
88. Clause SL, Triller DM. Problem with nebulized medications in a home health care patient. Am. J Health Syst Pharm 2002;59:1462-3.
89. Triller DM, Clause SL, Briceland LL et al. Resolution of drug-related problems in home care patients through a pharmacy referral service. Am J Health Syst Pharm 2003;60:905-10.
90. Salvatore T. Elder suicide: a preventable tragedy. Caring 2000;19:34-7.
91. Zeppetella G. How do terminally ill patients at home take their medication? Palliat Med 1999;13:469-75.
92. Ellenbecker CH, Frazier SC, Verney S. Nurses' observations and experiences of problems and adverse effects of medication management in home care. Geriatr Nurs 2004;25:164-70.
93. Montalto M. How safe is hospital-in-the-home care? Med J Aust 1998;168:277-80.
94. Dimond B. Intravenous therapy: duty of care and liability. Br J Nurs 2006;15:392-3.
95. What causes more than 40% of home care sentinel events?. Answer: fire: improve patient education and staff vigilance to ensure safety. Hospital Home Health 2004;21:13-5.
96. Odegard S, Andersson DK. Knowledge of diabetes among personnel in home-based care: how does it relate to medical mishaps? J Nurs Manag 2001;9:107-14.
97. Helleso R, Lorensen M, Sorensen L. Challenging the information gap-the patients transfer from hospital to home health care. Int J Med Inform 2004;73:569-80.
98. Home health: court blames nurses, in part, for patient's downhill course. Legal Eagle Eye Newsl Nursing Profession 2007;15:6.
99. ufseeser-Weiss MR, Ondeck DA. Medication use risk management: hospital meets home care. Home Health Care Manag Pract 2000;12:5-10.
100. Cohen H, Proulx S. Preventing medication errors in home care: applying system and process improvements. Infusion 1998;4:46-50.
101. Fick DM, Cooper JW, Wade WE et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003;163:2716-24.
102. Hamme M. Medication management educational tools for improving target outcomes: any emergent care. Home Healthc Nurse 2006;24:80-6.
103. Aufseeser-Weiss MR, Ondeck DA. Medication use risk management: hospital meets home care. J Nurs Care Qual 2001;15:50-7.
104. Wilder GL. Medication safety in home infusion care. J Infus Nurs 2003;26:311-8.
105. Snyder K. Home care and the law. Home health: a nurse's responsibility does not end upon recommending a patient go to the hospital. Home Healthc Nurse 2002;20:404.
106. Woomer N, Long CO, Anderson C et al. Benchmarking in home health care: a collaborative approach. Caring 1999;18:22-8.
107. Feldman PH, Bridges J, Peng T. Team structure and adverse events in home health care. Med Care 2007;45:553-61.
108. Ventilator patient: family saw patient in distress, but cannot sue. Legal Eagle Eye Newsl Nursing Profession 2004;12:7.
109. Pai MP, Mercier RC, Koster SA. Epidemiology of vancomycin-induced neutropenia in patients receiving home intravenous infusion therapy. Ann Pharmacother 2006;40:224-8.
110. Dobson PM, Boyle M, Loewenthal M. Home intravenous antibiotic therapy and allergic drug reactions: is there a case for routine supply of anaphylaxis kits? J Infus Nurs 2004;27:425-30.
111. Malani PN, DePestel DD, Riddell IVJ et al. Experience with community-based amphotericin B infusion therapy. Pharmacotherapy 2005;25:690-7.
112. Reimund JM, Arondel Y, Finck G et al. Catheter-related infection in patients on home parenteral nutrition: results of a prospective survey. Clin Nutr 2002;21:33-8.
113. Chenoweth CE, Washer LL, Obeyesekera K et al. Ventilator-associated pneumonia in the home care setting. Infect Control Hosp Epidemiol 2007;28:910-5.
114. Russon K, Sardesai AM, Ridgway S et al. Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure. Br J Anaesth 2006;97:869-73.
115. Manangan LP, Pearson ML, Tokars JI et al. Feasibility of national surveillance of health-care-associated infections in home-care settings. Emerg Infect Dis 2002;8:233-6.
116. Feldman PH, McDonald M, Rosati RJ et al. Exploring the utility of automated drug alerts in home healthcare. J Healthc Qual 2006;28:29-40.
117. Weick-Brady MD, Lazerow RN. Medical devices: promoting a safe migration into the home. Home Healthc Nurse 2006;24:298-304.
118. Nathwani D, Morrison J, Seaton RA et al. Out-patient and home-parenteral antibiotic therapy (OHPAT): evaluation of the impact of one year's experience in Tayside. Health Bull (Edinb) 1999;57:332-7.
119. Greenwald PW, Rutherford AF, Green RA et al. Emergency department visits for home medical device failure during the 2003 North America blackout. Acad Emerg Med 2004;11:786-9.
120. Fortinsky RH, Madigan EA, Sheehan TJ et al. Risk factors for hospitalization among medicare home care patients. West J Nurs Res 2006;28:902-17.
121. Joint Commission offers lessons in home care. Healthc Risk Manag 2001;23:55-6.
122. Suwanwela NC, Phanthumchinda K, Limtongkul S et al. Comparison of short (3-day) hospitalization followed by home care treatment and conventional (10-day) hospitalization for acute ischemic stroke. Cerebrovasc Dis 2002;13:267-71.
123. Foster L, Brown R, Phillips B et al. Improving the quality of Medicaid personal assistance through consumer direction. Health Aff 2003; SUPPL Web Exclusives:W3-75.
124. Shaughnessy PW, Crisler KS. Summary of the report on OASIS and Outcome-based Quality Improvement in Home Health Care: research and demonstration findings, policy implications, and considerations for future change. Centers for Medicare and Medicaid Services 2002. http://www.cms.hhs.gov/HomeHealthQualityInits/downloads/HHQIOASISReportSummary.pdf (7 October 2007, date last accessed).
125. Gill TM, Baker DI, Gottschalk M et al. A prehabilitation program for physically frail community-living older persons. Arch Phys Med Rehabil 2003;84:394-404.
126. Cox AM, Malani PN, Wiseman SW et al. Home intravenous antimicrobial infusion therapy: a viable option in older adults. J Amer Geriatr Soc 2007;55:645-50.
127. Tokars JI, Cookson ST, McArthur MA et al. Prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy... a peek at the past-a look at the future. The 2000 CINA conference, 18-20 October 2000. Reprinted with permission from Annals of Internal Medicine, 1999; 131(5):340-347. CINA: Official J Can Intravenous Nurses Assoc 2000;16:66-72.
128. Chang A, Enns R, Saqui O et al. Line sepsis in home parenteral nutrition patients: are there socioeconomic risk factors? A Canadian study. JPEN. J Parenter Enteral Nutr 2005;29:408-12.
129. Rosenheimer L, Embry FC, Sanford J et al. Infection surveillance in home care: device-related incidence rates. Am J Infect Control 1998;26:359-63.
130. Shah SS, Manning ML, Leahy E et al. Central venous catheterassociated bloodstream infections in pediatric oncology home care. Infect Control Hosp Epidemiol 2002;23:99-101.
131. Do AN, Ray BJ, Banerjee SN et al. Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting. J Infect Dis 1999;179:442-8.
132. Bergquist S, Frantz R. Braden scale: validity in communitybased older adults receiving home health care. Appl Nurs Res 2001;14:36-43.