Reporting incidents involving the use of advanced medical technologies by nurses in home care: a cross-sectional survey and an analysis of registration data

Abstract

BackgroundAdvanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systematically.ObjectivesTo identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents.MethodsA cross-sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used.ResultsWe identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation’s protocol.ConclusionsMost incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.

Attitudes of home-visiting nurses toward risk management of patient safety incidents in Japan

“…Thus, the importance of risk management needs to be recognized by both administrators and HVNs, who, together, must practice risk management to ensure the patient’s safety. Studies have reported that there is a need to improve patient safety in home care settings [ 9 , 15 ]. However, although adverse events in the home environment are likely to occur due to human factors, it has been pointed out that there is a lack of research on aspects such as risk management and human factors related to nurses [ 16 ].…”