Abstract

Purpose

The paper summarizes the results of a scoping review that focused on the occurrence of adverse events experienced by homecare patients.

Data sources

The literature search covered published and grey literature between 1998 and 2007. Databases searched included: MEDLINE, EMBASE, CINAHL and EBM REVIEWS including the Cochrane Library, AGELINE, the National Patient Safety Foundation Bibliography, Agency for Healthcare Research and Quality and the Patient Safety Net bibliography.

Study selection

Papers included research studies, review articles, policy papers, opinion articles and legal briefs. Inclusion criteria were: (i) homecare directed services provided in the home by healthcare professionals or caregivers; (ii) addressed a characteristic relevant to patient experienced adverse events (e.g. occurrences, rates, definitions, prevention or outcomes); and (iii) were in English.

Data extraction

A pool of 1007 articles was reduced to 168 after analysis. Data were charted according to six categories: definitions, rates, causes, consequences, interventions and policy.

Results

Eight categories emerged: adverse drug events, line-related, technology-related, infections and urinary catheters, wounds, falls, studies reporting multiple rates and other. Reported overall rates of adverse events ranged from 3.5 to 15.1% with higher rates for specific types. Few intervention studies were found. Adverse events were commonly associated with communication problems. Policy suggestions included the need to improve assessments, monitoring, education, coordination and communication.

Conclusion

A standardized definition of adverse events in the homecare setting is needed. Prospective cohort studies are needed to improve estimates and intervention studies should be undertaken to reduce the risk that homecare patients will experience adverse events.

Introduction

Adverse events occur in all healthcare delivery settings. To date, most research has focused on patients in hospitals and other settings; whereas, much less has targeted patients in homecare. Despite the lack of adverse event research in homecare, it is reasonable to expect that adverse events occur in all homecare settings. In addition, in homecare the number and types of professionals who need to communicate with each other and the client and caregiver may be large and they may rarely meet [1]. When compared with acute care, we know that homecare services are delivered differently and in a less structured setting. This presents policy implications at both organization and system levels. For example, McGraw et al. [2] argue that organizations ‘need to recognize that the challenges and hazards that exist in delivering primary health care in the home are very different from those in bounded organizational settings such as hospitals’. Lang et al. [3] further suggest that addressing safety in home care will require significant changes in the ‘underlying institutionally oriented assumptions and guiding frameworks’. Lang and Edwards [4] may have best described the issue by suggesting that we need to consider the fact that the home is designed for living and not for healthcare services.

Further complicating the environment is the trend towards an increased reliance upon family or other unpaid caregivers with sufficient attention to educating or training them. This adds complexity and clearly differentiates homecare from acute care. Safety concerns related to characteristics of the homecare patients’ local community environment can also be associated with patient and caregiver safety [2]. Thus the more complex yet less structured nature of homecare suggests that variables associated with adverse events in homecare differ from other settings and that the potential for adverse events in homecare may be higher than for patients in acute care or other institutional settings.

Adverse events in homecare will continue to emerge as an important health policy issue for other factors that include increased demand and cost. We can expect to see the demand for homecare to increase and to be driven by a combination of both population and health system characteristics that include demographic changes, technological advances, healthcare system restructuring and policy shifts and consumer preferences [5, 6]. With the rise in demand, we will typically see cost increases. For example, with the exception of drugs, homecare expenses in Canada have increased more rapidly than all other healthcare expenditures [5, 7].

Given the above, we need a better understanding of adverse events in the context of homecare. A summary of what is known and not known about adverse events in different international settings can help decision-makers identify and prioritize patient safety policy. In this paper, we present an overview of a longer report on homecare safety commissioned in 2007 by the Canadian Institutes of Health Research, Institute of Health Services and Policy Research [8]. Scoping reviews are designed to address this need and are typically used to draw on the main findings of research to present an overview of what is known on specific topics and to identify research gaps [9].

We limited our focus to patients who were receiving care under the direction of a homecare organization. This decision was based upon a research need identified by an Ontario homecare provider and our belief that this would provide valuable information on the potential for direct harm to patients. Nevertheless, we acknowledge that the overall topic is broad and that adverse events in homecare could be experienced by patients, providers, caregivers and family. The next section describes the methods and is followed by an overview of our key findings.

Methods

Adverse events experienced by homecare patients were identified as a priority issue by three Community Care Access Centres that were responsible for organizing the delivery of homecare services to 15 000 active clients in Ontario, Canada [10]. In a research agenda setting meeting, the main research question identified was: what is known from the existing literature about the occurrence of adverse events experienced by patients in the delivery of homecare services? To address this question, we used the five-stage methodological framework for conducting scoping studies developed by Arksey and O'Malley [9]: (i) identifying the research question; (ii) identifying relevant studies; (iii) study selection for more detailed analysis; (iv) charting the data; and (v) collating, summarizing and reporting the results. The operational definition of adverse events applied in this study is a modified version of the one used by Masotti et al. [10]: ‘events or occurrences which become apparent during the delivery of home care services, and which have a negative impact on patient care, patient outcomes, family or support care and resources utilization’. Specifically, our focus was on the potential for harm to patients. Given this we excluded adverse events experienced by individuals other than the homecare patient.

Purpose

Our purpose was to map the extent and range of existing research and other relevant literature. In scoping review studies (unlike systematic reviews), researchers do not evaluate the quality of the studies. Scoping review studies are generally intended to draw on the main findings of research and to present an overview of what is known on the specific topic. O'Malley and Croucher [11] suggest that scoping reviews can be seen as a: ‘preliminary attempt to provide an overview of existing literature that identifies areas where more research might be required’.

Data sources

The literature search covered indexed and unindexed published literature and grey literature during the 1998–2007 time period. Major databases consulted for the indexed published literature were: MEDLINE, EMBASE, CINAHL and EBM REVIEWS including the Cochrane Library and AGELINE. Additionally, the National Patient Safety Foundation Bibliography and the Agency for Healthcare Research and Quality and Patient Safety Net bibliography, both of which are dedicated specifically to the study of patient safety, were searched. Search strategies for each database were developed using natural language text words and controlled vocabulary terms specific to each database, I.E. MeSH, Emtree headings, Cinahl headings and Thesaurus of Aging Terminology headings for MEDLINE, EMBASE, CINAHL and Ageline, respectively. In addition, 13 journals, considered appropriate for homecare and patient safety, were searched manually. This was followed by a World Wide Web search using Google Advanced mode to identify relevant grey literature. The grey literature search was limited to Canadian content. We included both federal and provincial health ministry websites and major Canadian organizations involved in patient safety and homecare.

Data extraction

Papers eligible for review included research studies, review articles, policy papers, opinion articles and legal briefs. Specific inclusion criteria were: (i) homecare/healthcare related services provided in the home; (ii) services were provided by a healthcare professional or caregiver under the direction of homecare professionals; and (iii) addressed some characteristic relevant to adverse events experienced by patients (e.g. occurrences, rates, definitions, policy, prevention or outcomes). Papers were excluded if they (i) were non-English; (ii) did not specifically address patient-experienced adverse events; or (iii) addressed ambulatory/out-patients or services generally not supervised by homecare. The purpose of the inclusion and exclusion criteria was to ensure that the papers addressed both care that was provided under the direction of homecare organizations and some aspect of adverse events experienced by patients. The timing of the adverse event (antecedent or outcome) including whether paid providers or caregivers were present was not part of the inclusion/exclusion criteria.

A preliminary pool of 1007 articles was identified using the search strategies. Titles and abstracts were reviewed using the inclusion/exclusion criteria and resulted in a total of 340 papers selected for full review in more detail. A detailed analysis of the 340 papers resulted in a selection of 193 papers that was further reduced to 168 following team adjudication of papers that were considered a questionable fit for the inclusion criteria. Data from the final 168 papers were charted according to the following categories: (i) definitions and types; (ii) rates (incidence/prevalence); (iii) causes; (iv) consequences; (v) interventions; and (vi) policy suggestions/implications. Where appropriate this data was further charted depending upon its specific relevance to patients, providers, healthcare organizations or the health system.

Results

In this general overview, we present the results in the following order: (i) definitions issues that emerged; (ii) studies reporting multiple adverse event rates; (iii) adverse event analysis categories that emerged from our analysis; (iv) prevalence/incidence rates; (v) causes; (vi) consequences; and (vii) interventions.

Definitions

An adverse event is a term that is used frequently in the literature. However, there does not appear to be a commonly accepted standardized definition for adverse events that occur in homecare. Differences in definitions used vary based upon outcomes such as the requirement for harm or increased resources utilization versus the potential for these to occur. Examples that illustrate the differences are in Table 1. The literature indicated a need for clarity and standardization regarding what truly constitutes an adverse event. For example, there are times when the same conditions exist (e.g. medication error, patient characteristics or other antecedents) but result in different outcomes (e.g. injury versus no observable injury). There also appears to be a lack of clarity regarding what is an adverse event and what is the consequence of an adverse event. For example, unplanned hospitalizations or emergent care have been both described as an adverse event and the consequence or outcome of an adverse event.

Table 1

Adverse event definitions

Author/organization Definition 
Caplan et al. [17Unintended injury or complication—only if it results in disability, death or prolonged hospital stay and is caused by healthcare management 
USA—Centers for Medicare & Medicaid Services [15Low frequency-negative or untoward event that potentially reflects a serious health problem or decline in health status for an individual patient 
Masotti et al. [10Events or occurrences, which become apparent during the delivery of homecare services and which have a negative or potentially negative impact on patient care, patient outcomes, family or support care and resources utilization. 
Johnson [16Any harm to the client that negatively affects their overall health and/or functioning and is the result of care actions and/or inactions rather than the client's underlying condition. 
Author/organization Definition 
Caplan et al. [17Unintended injury or complication—only if it results in disability, death or prolonged hospital stay and is caused by healthcare management 
USA—Centers for Medicare & Medicaid Services [15Low frequency-negative or untoward event that potentially reflects a serious health problem or decline in health status for an individual patient 
Masotti et al. [10Events or occurrences, which become apparent during the delivery of homecare services and which have a negative or potentially negative impact on patient care, patient outcomes, family or support care and resources utilization. 
Johnson [16Any harm to the client that negatively affects their overall health and/or functioning and is the result of care actions and/or inactions rather than the client's underlying condition. 

In the adverse drug event literature, we found that it was common to use the term adverse drug events when the focus was on the discussion or reporting of occurrences of problems such as polypharmacy or medication related errors such as: administration errors, wrong dose or inappropriate medications. This also highlighted issues relating to operational definitions of what constitutes an adverse event versus the antecedent or outcome of an adverse event.

Studies reporting multiple/overall adverse event rates

Comparing the adverse event rates reported in the different studies in each country presents challenges based upon study differences such as: (i) operational definitions for adverse events; (ii) the different adverse event types that were evaluated; and (iii) different patient populations. For example, the Australian studies evaluated hospital-in-the-home patients who may not have the same characteristics as Medicare/Medicaid patients in the USA. Table 2 illustrates the different adverse event types evaluated in three different studies.

Table 2

Adverse event types evaluated in three studies in three countries

USA—OASIS (Madigan [14]) Canada (Johnson [16]) Australia (Liu and Taylor [18]) 
1. Emergent care for injury caused by a fall or accident i. Injuries/falls a. Allergic reaction to medication/dressing 
2. Increase in the number of pressure ulcers ii. Non-injury falls b. Gastrointestinal effect of medication 
3. Emergent care for improper medication admin/side effects iii. Pressure ulcers c. Other 
4. Substantial decline in management of oral medications iv. Medication related d. Post-operative wound infections 
5. Unexpected nursing home admission v. Mental harm/injury e. Deep venous thrombosis 
6. Emergent care for wound infections, deteriorating wound status vi. Other f. Haemorrhage due to anticoagulation 
7. Emergent care for hypo/hyperglycemia  g. Failed diagnosis 
8. Development of UTI  h. Failed treatment 
9. Substantial decline in three or more ADLs   
10. Discharged to the community needing wound care/meds assistance   
11. Discharged to the community needing toileting assistance   
12. Discharged to the community with behavioral problems   
13. Unexpected death   
USA—OASIS (Madigan [14]) Canada (Johnson [16]) Australia (Liu and Taylor [18]) 
1. Emergent care for injury caused by a fall or accident i. Injuries/falls a. Allergic reaction to medication/dressing 
2. Increase in the number of pressure ulcers ii. Non-injury falls b. Gastrointestinal effect of medication 
3. Emergent care for improper medication admin/side effects iii. Pressure ulcers c. Other 
4. Substantial decline in management of oral medications iv. Medication related d. Post-operative wound infections 
5. Unexpected nursing home admission v. Mental harm/injury e. Deep venous thrombosis 
6. Emergent care for wound infections, deteriorating wound status vi. Other f. Haemorrhage due to anticoagulation 
7. Emergent care for hypo/hyperglycemia  g. Failed diagnosis 
8. Development of UTI  h. Failed treatment 
9. Substantial decline in three or more ADLs   
10. Discharged to the community needing wound care/meds assistance   
11. Discharged to the community needing toileting assistance   
12. Discharged to the community with behavioral problems   
13. Unexpected death   

Seven studies in three countries (one in Canada; three in USA; three in Australia) reported rates for overall or multiple adverse event types. Rates reported ranged from 3.5 to 15.1% [12–18]. Johnson [16] found a 5.5% rate in a random sample of 400 Winnipeg homecare clients. The American studies reported results of large sample studies that evaluated the Outcome and Assessment Information Set (OASIS) database that includes reporting for 13 specific adverse event outcomes for all Medicare/Medicaid homecare patients. In one example, Madigan evaluated the entire 2003 OASIS database comprising 3 013 287 patients and found a 13.1% overall rate [14]. Although these studies were not prospective cohort studies with extensive chart reviews, the results clearly suggest that adverse events occur frequently and the American studies also suggested that rates for some types are similar across time and different locations (Table 3).

Table 3

Adverse event rates in two American studies

OASIS adverse event Crisler and Richard Madigan et al.
 
 September 1999 to August 2000 October 2000 to December 2000 January 2001 to March 2001 
Emergent care for injury caused by a fall or accident 1.7 1.7 1.4 
Emergent care for wound infections, deteriorating wound status 1.9 1.6 1.4 
Emergent care for improper medication admin, medication side effects 0.7 0.7 0.7 
Emergent care for hypo/hyperglycemia 0.6 0.6 0.8 
Development of UTI 1.1 1.4 1.4 
Increase in the number of pressure ulcers 0.4 1.4 1.9 
Substantial decline in 3 or more ADLs 0.5 0.5 0.4 
Substantial decline in management of oral medications 0.5 0.5 0.8 
Unexpected nursing home admission 3.9 0.7 0.6 
Discharged to the community needing wound care or medication assistance. 0.5 0.5 0.2 
Discharged to the community needing toileting assistance 0.2 0.3 0.1 
Discharged to the community with behavioral problems 0.8 0.9 0.4 
Unexpected death 1.1 3.4 1.0 
OASIS adverse event Crisler and Richard Madigan et al.
 
 September 1999 to August 2000 October 2000 to December 2000 January 2001 to March 2001 
Emergent care for injury caused by a fall or accident 1.7 1.7 1.4 
Emergent care for wound infections, deteriorating wound status 1.9 1.6 1.4 
Emergent care for improper medication admin, medication side effects 0.7 0.7 0.7 
Emergent care for hypo/hyperglycemia 0.6 0.6 0.8 
Development of UTI 1.1 1.4 1.4 
Increase in the number of pressure ulcers 0.4 1.4 1.9 
Substantial decline in 3 or more ADLs 0.5 0.5 0.4 
Substantial decline in management of oral medications 0.5 0.5 0.8 
Unexpected nursing home admission 3.9 0.7 0.6 
Discharged to the community needing wound care or medication assistance. 0.5 0.5 0.2 
Discharged to the community needing toileting assistance 0.2 0.3 0.1 
Discharged to the community with behavioral problems 0.8 0.9 0.4 
Unexpected death 1.1 3.4 1.0 

Values are represented in percentage. Crisler and Richard [13] reported overall USA rates/reference points for the 13 Adverse Event Outcomes in the OASIS data set used by the Centers for Medicare and Medicaid. Madigan et al. [15] looked at rates in both Ohio and Michigan during two time periods: October to December 2000 and January to March 2001.

Adverse event analysis categories

We identified eight thematic categories that were distinct enough to warrant category-specific analyses. Six categories address specific adverse event types, whereas the remaining two categories were broader in scope. We acknowledge that other appropriate categories exist and that the categories we identified may not be mutually exclusive. The number of papers per category are: (i) adverse drug events (42), (ii) line-related (33), (iii) technology-related (16), (iv) infections and urinary catheters (11), (v) wounds (10), (vi) falls (7), (vii) studies reporting multiple/overall rates (7), and (viii) other (42).

Category definitions/criteria

Adverse drug events are typically defined as injuries resulting from medical interventions relating to the use of a drug [19]. The line-related adverse event category included adverse event associated with medical interventions that included the insertion of a line through the skin and other tissue. Examples of three commonly reported line-related adverse events include: (i) line/catheter occlusion; (ii) catheter site infections; and (iii) catheter-related blood stream infections [20–42]. Technology-related adverse events are associated with the use of medical equipment and technology used to deliver health care and include oxygen therapy, ventilators, dialysis and equipment/computer operational failures [43–55]. Adverse events in the infections and urinary catheter-related category excluded line-related and wound-related infections. Examples of three commonly reported adverse events in this category were urinary tract infections (UTIs), community-acquired pneumonia and hospital-acquired infections [7, 33, 34, 56–60]. Adverse events in the wounds category were associated with disruptions in structural integrity and included surgical, burns, infections, pressure-ulcers and vascular-leg ulcers. Falls were adverse events associated with injury caused by unplanned movements to the ground or another plane [61]. Papers in the other adverse event category typically addressed topics that include healthcare policy, legal issues, general patient safety and reporting and data collection. Papers in the multiple/overall rates category evaluated patient populations for multiple types of adverse events that typically were not limited to a specific adverse event type such as adverse drug events.

Prevalence/incidence rates

The previous section, ‘studies reporting multiple/overall adverse event rates’, was limited to seven papers and did not provide an adequate description of what the literature revealed about adverse event rates in homecare. Table 4 illustrates specific rates. The following provides a general overview of results for the specific analysis categories. The prevalence estimates given below should be interpreted with caution because of variations in study design and sampling.

Table 4

Reported adverse event rates by type

Category Reported rates 
Adverse drug events 3.64–72% [62, 63, 73, 81, 89, 109–111, 116, 118, 126
Line-related adverse events 
 Catheter-related blood stream infection 0.19–3.3/1000 catheter days [27, 28, 112, 127–131
 Catheter site infections 0.4–2.1/1000 catheter days [29, 31, 34, 36
 Line/catheter occlusion 0.51–3.1/1000 catheter days [27–29, 31
3.7–9.1% [27–29, 31
 Associated with home parenteral nutrition 34% [39
Technology related 
 Associated with home ventilators 189 events per 150 patients in 1 year [43
Infections and urinary catheters 
 Community-acquired pneumonia 25/1000 person years [56
 Hospital-acquired infections 6.3/100 [58
1.04 infections/infected patient ratio [58
 Ventilator-associated pneumonia 0.87–1.93 infections/1000 ventilator days [113
 UTI 2.79–3.4/1000 catheter days [34, 59, 106
43% with indwelling catheters [59
Wounds 
 Overall prevalence 20% [72
 Pressure ulcers 2–6% [15, 132
 Homecare-acquired infections/other complications 1.4% [15
Falls 27% onetime [75
10% ≥1 [75
Category Reported rates 
Adverse drug events 3.64–72% [62, 63, 73, 81, 89, 109–111, 116, 118, 126
Line-related adverse events 
 Catheter-related blood stream infection 0.19–3.3/1000 catheter days [27, 28, 112, 127–131
 Catheter site infections 0.4–2.1/1000 catheter days [29, 31, 34, 36
 Line/catheter occlusion 0.51–3.1/1000 catheter days [27–29, 31
3.7–9.1% [27–29, 31
 Associated with home parenteral nutrition 34% [39
Technology related 
 Associated with home ventilators 189 events per 150 patients in 1 year [43
Infections and urinary catheters 
 Community-acquired pneumonia 25/1000 person years [56
 Hospital-acquired infections 6.3/100 [58
1.04 infections/infected patient ratio [58
 Ventilator-associated pneumonia 0.87–1.93 infections/1000 ventilator days [113
 UTI 2.79–3.4/1000 catheter days [34, 59, 106
43% with indwelling catheters [59
Wounds 
 Overall prevalence 20% [72
 Pressure ulcers 2–6% [15, 132
 Homecare-acquired infections/other complications 1.4% [15
Falls 27% onetime [75
10% ≥1 [75

Adverse drug events and line-related adverse events were the most frequently reported and had the highest proportion of events. Johnson [16] found that adverse drug events represented 23.1% of all adverse events in a sample of Canadian homecare clients, whereas the Joint Commission on Patient Safety indicated that 20–30% of homecare patients were at risk for medication errors and that when errors occurred in the home, 12% of the patients experienced harm (Note: reported medication error rates, which do not always result in adverse events, ranged from 19 to 77%) [62–71]. The most frequently reported types of line-related adverse events were catheter-related blood stream infections, catheter site infections and line/catheter occlusions.

There were fewer studies that reported adverse event rates for the remaining categories. However, Johnson [16] found that falls represented 61% of all types of adverse events experienced and that 46% of falls resulted in injury. When discussing wounds, Madigan [14] suggested that 60% of homecare referrals required wound management. In addition, a 20% point prevalence wound rate has been reported [72]. Infections also occur frequently. For example, Mananagan et al. [33] reported that 16% of the 5148 homecare patients in their study had infections during the study period and that 8% of those were homecare acquired and of the infections 50% were UTIs and 37.9% were skin infections. In another study, Patte et al. [58] reported a hospital-acquired infection rate of 6.3/100 in sample of 376 homecare patients. In addition, home ventilator use was associated with predictable equipment failure rates [43, 44]. This suggests that other technology-related adverse event rates may also be predictable given that both human error and equipment failure are likely to occur.

Causes

Our methods included the assumption that factors associated with the cause or increased risk of adverse events could be grouped into two broad categories: (i) patient-level characteristics (includes patient, home environment and caregiver/family) and (ii) healthcare organization and system-level characteristics. Our definition of healthcare organizations included homecare agencies and their associated staff, and other clinical providers who work with patients. Many papers in all adverse event analysis categories provided information (both evidence based and opinion based) that addressed causes of adverse events.

Patient-level characteristics

Commonly reported patient-level characteristics associated with cause or increased risk were (i) increased age and co-morbidities [14, 15, 18, 56, 58, 61, 63, 66, 67, 73–80]; (ii) gender [14, 66, 67, 81]; (iii) depression, cognitive impairments, functional status/limitations [14, 56, 58, 62, 64, 66, 67, 73, 80–88]; (iv) patient compliance [73, 80, 82, 83, 89–91]; and (v) living alone or no caregiver [63, 65, 67, 80, 92].

Organization and system-level characteristics

Across the literature it was clear that communication issues (including patient education) and/or local system-level integration issues, such as coordination and collaboration, were believed to be associated with the primary causes of adverse events [14, 16, 56, 63–65, 73, 75, 80, 82, 86, 87, 89, 91–105]. Other commonly reported factors associated with cause or increased risk included: (i) team experience, training or knowledge [74, 79, 84, 87, 92, 100, 103, 106–108]; (ii) team workload [73, 74, 99, 103, 106]; (iii) medication errors [19, 62, 70, 73, 85, 89, 92, 108]; (iv) unrecognized polypharmacy [63, 65, 66, 85, 86, 92]; (v) drug label instructions [87, 88, 100]; and (vi) inadequate patient monitoring/assessment [63, 67, 74, 87, 100, 102, 108].

Consequences

As expected and aligned with the different definitions for adverse events, reported consequences exist on a continuum that can range from barely observable occurrences to those that have high health and economic costs. Examples of health consequences include functional loss or decline, illness, temporary injury/pain, permanent injury/harm, and death [13, 16–18, 21, 25, 28, 31, 35, 39, 56, 59, 63, 70, 73, 74, 80, 88, 92, 104, 105, 108–115]. Economic consequences include increased need for treatment or care, increased patient or caregiver time and unplanned hospitalization [16–18, 20–22, 24, 27, 28, 31, 35, 36, 42, 56, 59, 73, 80, 81, 101, 102, 105, 110–119]. In addition, in the Canadian study that evaluated multiple adverse event rates, Johnson [16] reported that 69.3% of the adverse events resulted in temporary harm, 4% in permanent harm, 4% in permanent placement and 15.4% resulted in unneeded hospitalizations. Franklin [74] also suggested that harm is more likely to result from adverse events associated with intravenous errors because of the immediate absorption of the drug and the inability to recall it after it is given. Whereas, Fortinsky found that 9% of homecare patients were hospitalized due to wounds (compared with 7% for falls, the next most frequent cause). Fortinsky [120] also reported that the odds of being hospitalized were much higher for a homecare patient with a wound versus one without.

Other reported consequences of interest include the following: (i) burns associated with patients on oxygen therapy who smoke [121]; (ii) patient initiated lawsuits [53, 98]; (iii) delayed therapy [22, 28, 118]; and (iv) increased emergency room visits for patients on ventilators, home oxygen and suction machines following power outages [119].

Interventions

To be identified as an intervention, the main criteria used was the requirement that the article discussed or presented evidence of a formal program that was designed with the objective of identifying adverse events, decreasing rates or reducing their impact.

Our analysis revealed an abundance of policy or best practice suggestions regarding preventing adverse events; however, there was a paucity of actual intervention models or intervention effectiveness studies. For example, we only found a total of 18 interventions documented in five of the eight categories: adverse drug events (4); line-related adverse events (3); wounds (2); falls (4) and other adverse events (5). However, many of the examples we included did not meet full inclusion criteria for our operational definition of interventions.

Characteristics of intervention models the authors considered successful or potentially effective included (i) improving staff knowledge and training; (ii) increased patient monitoring and reporting by providers; (iii) use of computerized screening to identify potential adverse drug events; (iv) implementing required standardized reporting; (v) improved collaboration/communication between local providers (acute care, primary care and homecare); (vi) using an appropriate interdisciplinary team mix; (vii) focus on both patient (includes home and caregivers) and provider level characteristics; and (viii) targeting identified adverse events for further comprehensive investigation into patient-level and provider-level characteristics [13, 15, 31, 60, 65, 72, 76, 78, 86, 89, 102, 122–125].

Conclusions

Implications

Our findings are the result of a comprehensive five-stage structured approach to conducting a review of the body of English language indexed and unindexed literature that was published/made available during the 1998–2007 time period. Our scoping review identified six key categories of events recognized in the published literature: adverse drug events, line related, technology related, infections/urinary catheters, wounds and falls. Although these categories were the ones that emerged from our review, we recognize that other appropriate categories or sub-categories exist. Given this, we suggest that a better understanding of adverse events in homecare would result from research that utilizes a typology that places similar adverse event types into appropriate categories for evaluation based upon shared characteristics (e.g. biological, causes, outcomes, patient sub-populations, provider-level characteristics and treatment type). For example, gender-based analyses would be appropriate given that women live longer and consequently may have the unfortunate experience of transitioning from caregiver to patient.

A second finding of this study relates to the relatively small international body of evidence addressing overall adverse event incident and prevalence rates. The results of our scoping review suggest that it is reasonable to conclude that adverse events in homecare occur frequently and with some degree of predictability for specific types. However, one should not interpret the results to reflect the true experience of homecare patients in multiple homecare settings. This assertion is based upon the following: (i) few studies reported rates and evaluating the quality of those studies was outside of the scope of this scoping review study; (ii) none of the studies were large sample prospective cohort studies; (iii) different adverse event definitions were used and studies did not evaluate the same groups of adverse event types; and (iv) some adverse event types still need to be identified and defined before they can be documented. Given this, we hypothesize that the actual rates experienced by homecare patients could be higher. Consequently, we suggest that measuring the rates of adverse events in homecare settings should be considered a priority health policy issue.

One conclusion from our research was that policy aimed at preventing or reducing the impact of adverse events will need to target multilevel changes (e.g. patient, caregiver, home environment, provider, organization and healthcare system levels). The literature clearly indicated that between and within organization communication issues (includes patient and caregiver education), provider education and local health system-level integration issues were perceived to be associated with primary causes of adverse events. There is a clear need for a system-level approach that includes increased focus on caregivers and the home environment. In addition, system-wide initiatives that will support the continued ability to understand adverse events and improve patient safety include: (i) acceptance and implementation of a standardized definition for adverse events and for specific adverse event types; (ii) required data collection and reporting of specific adverse events; and (iii) system-wide surveillance. However, effective policy will require more knowledge and consequently, more research.

Research needs

In general, there is a need for multiple large sample cohort studies designed to improve our understanding of characteristics associated with the occurrence of adverse events. Ideally, this research would increase our understanding of rates, risks and outcomes for specific adverse event types in different homecare subpopulations and under different models of delivery. This research should evaluate patient-level, provider/organization-level and local healthcare system-level factors associated with adverse events as well as the relationships between the different levels.

This scoping review study revealed three primary research areas that need to be addressed to increase our knowledge about adverse events in homecare: (i) incidence rates (e.g. for multiple adverse event types and homecare patients with different characteristics); (ii) multi-level variables associated with the occurrence of adverse events (e.g. patient/provider/system-level variables associated with causes and consequences); and (iii) information on effective interventions and best practices (e.g. to identify, prevent or reduce the impact of adverse events). However, a first step in effectively approaching these research areas would be the development and acceptance of a standardized definition for an adverse event and for specific adverse event types.

Funding

This work was supported by the Canadian Institutes of Health Research—Institute of Health Services and Policy Research.

Acknowledgements

We would also like to acknowledge the contributions of Margaret Darling and Nadia Zurba from the Centre for Health Services and Policy Research, Queen's University.

References

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
McGraw
C
Drennan
V
Humphrey
C
Understanding risk and safety in home health care: the limits of generic frameworks
Qual Prim Care
 , 
2008
, vol. 
16
 (pg. 
239
-
48
)
Lang
A
Edwards
N
Fleiszer
A
Safety in home care: a broadened perspective of patient safety
Int J Qual Health Care
 , 
2008
, vol. 
20
 (pg. 
130
-
5
)
Lang
A
Edwards
N
Safety in home care: broadening the patient safety agenda to include home care services
 
Coyte
PC
McKeever
P
Home care in Canada: passing the buck
Can J Nurs Res
 , 
2001
, vol. 
33
 (pg. 
11
-
25
)
Richardson
B
Implementing home care in Canada: four critical elements
Healthc Pap
 , 
2000
, vol. 
1
 (pg. 
67
-
73
discussion
Health Canada
Public home care expenditures in Canada, 1975–76 to 1997–98
 
Masotti
P
McColl
M
Green
M
Assessment of Adverse Events in Canadian Home Care: A Scoping Review
2008
Queen's University: Centre for Health Services and Policy Research
 
Report submitted to the Canadian Institutes of Health Research Available at http://chspr.queensu.ca/
Arksey
H
O'Malley
L
Scoping studies: towards a methodological framework
Int J Soc Res Methods
 , 
2005
, vol. 
8
 (pg. 
19
-
32
)
Masotti
P
Green
M
Shortt
SE
, et al.  . 
Adverse events in community care: developing a research agenda
Healthc Q
 , 
2007
, vol. 
10
 (pg. 
59
-
65
)
O'Malley
L
Croucher
K
Housing and dementia care—a scoping review of the literature
Health Soc Care Community
 , 
2005
, vol. 
13
 (pg. 
570
-
7
)
Leff
B
Montalto
M
Hospital at home: potential in geriatric healthcare and future challenges to dissemination
Aging Health
 , 
2006
, vol. 
2
 (pg. 
701
-
3
)
Crisler
KS
Richard
AA
Using case mix and adverse event outcome reports for outcome-based quality monitoring
Home Healthc Nurse
 , 
2001
, vol. 
19
 (pg. 
613
-
21
)
Madigan
EA
A description of adverse events in home healthcare
Home Healthc Nurse
 , 
2007
, vol. 
25
 (pg. 
191
-
7
)
Madigan
EA
Tullai-McGuinness
S
An examination of the most frequent adverse events in home care agencies
Home Healthc Nurse
 , 
2004
, vol. 
22
 (pg. 
256
-
62
)
Johnson
KG
Adverse events among Winnipeg Home Care clients
Healthc Q
 , 
2006
, vol. 
9
  
spec no. 127-34
Caplan
GA
Ward
JA
Brennan
NJ
, et al.  . 
Hospital in the home: a randomised controlled trial
Med J Aust
 , 
1999
, vol. 
170
 (pg. 
156
-
60
)
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
, vol. 
14
 (pg. 
400
-
5
)
Bates
DW
Cullen
DJ
Laird
N
, et al.  . 
Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group
JAMA
 , 
1995
, vol. 
274
 (pg. 
29
-
34
)
Steinmetz
D
Berkovits
E
Edelstein
H
, et al.  . 
Home intravenous antibiotic therapy programme, 1999
J Infect
 , 
2001
, vol. 
42
 (pg. 
176
-
80
)
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
, vol. 
13
 (pg. 
1009
-
16
)
Gorski
LA
Central venous access device occlusions: part 2: nonthrombotic causes and treatment
Home Healthc Nurse
 , 
2003
, vol. 
21
 (pg. 
168
-
71
)
Berger
L
The effects of positive pressure devices on catheter occlusions
J Vasc Access Devices
 , 
2000
, vol. 
5
 (pg. 
31
-
3
)
Herbst
SL
Kaplan
LK
McKinnon
BT
Vascular access devices: managing occlusions and related complications in home infusion
Infusion
 , 
1998
, vol. 
4
 (pg. 
1
-
32
)
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
, vol. 
12
 (pg. 
33
-
7
)
Berg
AM
Snell
L
Mahle
WT
Home inotropic therapy in children
J Heart Lung Transplant
 , 
2007
, vol. 
26
 (pg. 
453
-
7
)
Gorski
LA
Central venous access device outcomes in a homecare agency: a 7-year study
J Infus Nurs
 , 
2004
, vol. 
27
 (pg. 
104
-
11
)
Ryder
M
Evidence-based practice in the management of vascular access devices for home parenteral nutrition therapy
JPEN J Parenter Enteral Nutr
 , 
2006
, vol. 
30
 (pg. 
S82
-
S93
)
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
, vol. 
21
 (pg. 
156
-
60
)
Wade
BH
Bush
SE
Infection control and outpatient parenteral antibiotic therapy
Infect Dis Clin North Am
 , 
1998
, vol. 
12
 (pg. 
979
-
94
)
Buchman
AL
Complications of long-term home total parenteral nutrition: their identification, prevention and treatment
Dig Dis Sci
 , 
2001
, vol. 
46
 (pg. 
1
-
18
)
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
, vol. 
36
 (pg. 
420
-
4
)
Increasing use of devices fuels infections in home care: national infection control efforts lag
Hosp Infect Control
 , 
2000
, vol. 
27
 (pg. 
1
-
3
)
Luehm
D
Fauerbach
L
Task force studies. Infection rates, surgical site management, & foley catheter infections
Caring
 , 
1999
, vol. 
18
 (pg. 
30
-
4
)
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
, vol. 
30
 (pg. 
215
-
21
)
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
, vol. 
19
 (pg. 
355
-
9
)
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
, vol. 
17
 (pg. 
970
-
1
)
Hoffman-Terry
ML
Fraimow
HS
Fox
TR
, et al.  . 
Adverse effects of outpatient parenteral antibiotic therapy
Am J Med
 , 
1999
, vol. 
106
 (pg. 
44
-
9
)
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
, vol. 
29
 (pg. 
74
-
80
)
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
, vol. 
9
 (pg. 
715
-
7
)
Moreno
JM
Valero
MA
Gomis
P
, et al.  . 
Central venous catheter occlusion in home parenteral nutrition patients
Clin Nutr
 , 
1998
, vol. 
17
 (pg. 
35
-
6
)
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
, vol. 
57
 (pg. 
612
-
5
)
Srinivasan
S
Doty
SM
White
TR
, et al.  . 
Frequency, causes, and outcome of home ventilator failure
Chest
 , 
1998
, vol. 
114
 (pg. 
1363
-
7
)
Simonds
AK
Risk management of the home ventilator dependent patient
Thorax
 , 
2006
, vol. 
61
 (pg. 
369
-
71
)
Bruno
L
Ahrens
J
Examining ‘operational failures’ to reduce home care errors
Caring
 , 
2005
, vol. 
24
 (pg. 
34
-
9
)
Tucker
AL
A case study of operational failure in home healthcare
J Healthc Qual
 , 
2004
, vol. 
26
 (pg. 
38
-
43
)
Baruchin
O
Yoffe
B
Baruchin
AM
Burns in inpatients by simultaneous use of cigarettes and oxygen therapy
Burns
 , 
2004
, vol. 
30
 (pg. 
836
-
8
)
Chang
TT
Lipinski
CA
Sherman
HF
A hazard of home oxygen therapy
J Burn Care Rehabil
 , 
2001
, vol. 
22
 (pg. 
71
-
4
)
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
, vol. 
23
 (pg. 
73
-
5
)
MacAdam
M
Examining home care in other countries: the policy issues
Home Health Care Manag Pract
 , 
2004
, vol. 
16
 (pg. 
393
-
404
)
Cusick
JM
Burn Prevention Forum
J Burn Care Rehabil
 , 
2001
, vol. 
22
 (pg. 
70
-
1
)
Home health: nurse was an employee
Legal Eagle Eye Newsl Nursing Profession
 , 
2002
, vol. 
10
 pg. 
8
 
Abood RR. Legal issues
Products liability in home health care
Home HealthCare Consult
 , 
1998
, vol. 
5
 (pg. 
21
-
5
)
Tammelleo
AD
‘Preemie’ dies on home health nurse's watch
Nurs Law Regan Rep
 , 
2004
, vol. 
44
 pg. 
1
 
Ing
TS
Kohn
O
Fire hazards related to the use of dialysis machines
Int J Artif Organs
 , 
2005
, vol. 
28
 pg. 
1053
 
Marrie
TJ
Huang
JQ
Community-acquired pneumonia in patients receiving home care
J Am Geriatr Soc
 , 
2005
, vol. 
53
 (pg. 
834
-
9
)
Long
CO
Anderson
C
Greenberg
EA
, et al.  . 
Defining and monitoring indwelling catheter-related urinary tract infections
Home Healthc Nurse
 , 
2002
, vol. 
20
 (pg. 
255
-
62
)
Patte
R
Drouvot
V
Quenon
JL
, et al.  . 
Prevalence of hospital-acquired infections in a home care setting
J Hosp Infect
 , 
2005
, vol. 
59
 (pg. 
148
-
51
)
Newman
DK
Managing indwelling urethral catheters
Ostomy Wound Manage
 , 
1998
, vol. 
44
 (pg. 
26
-
32
)
Hardyck
C
Petrinovich
L
Reducing urinary tract infections in catheterized patients
Ostomy Wound Manage
 , 
1998
, vol. 
44
 (pg. 
36
-
43
)
Bucher
GM
Szczerba
P
Curtin
PM
A comprehensive fall prevention program for assessment, interventions, and referral
Home Healthc Nurse
 , 
2007
, vol. 
25
 (pg. 
174
-
83
)
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
, vol. 
24
 (pg. 
29
-
45
)
Root causes: getting to the bottom of medication errors in home care
JCAH Perspect
 , 
2004
, vol. 
4
 (pg. 
5
-
6
)
Temp worker's mistake costs a life and $800,000
J Healthc Risk Manage
 , 
2003
Ahrens
J
Feldman
PH
Frey
D
Preventing medication errors in home care
Cent Home Care Policy Res
 , 
2002
, vol. 
12
 (pg. 
1
-
6
)
Meredith
S
Feldman
PH
Frey
D
, et al.  . 
Possible medication errors in home healthcare patients
J Am Geriatr Soc
 , 
2001
, vol. 
49
 (pg. 
719
-
24
)
Fialova
D
Topinkova
E
Gambassi
G
, et al.  . 
Potentially inappropriate medication use among elderly home care patients in Europe
JAMA
 , 
2005
, vol. 
293
 (pg. 
1348
-
58
)
Ahrens
J
Combatting medication errors in home health
Caring
 , 
2003
, vol. 
22
 (pg. 
56
-
9
)
Frey
D
The medication management model: an effective tool for home health providers
Home Health Care Manage Pract
 , 
2003
, vol. 
15
 (pg. 
222
-
30
)
Golden
AG
Preston
RA
Barnett
SD
, et al.  . 
Inappropriate medication prescribing in homebound older adults
J Am Geriatr Soc
 , 
1999
, vol. 
47
 (pg. 
948
-
53
)
Higher risk of medication errors for seniors: home health bigger challenge: use guidelines specific to elderly, and monitor errors
Hospital Home Health
 , 
2002
, vol. 
19
 (pg. 
85
-
8
)
Sturkey
EN
Linker
S
Keith
DD
, et al.  . 
Improving wound care outcomes in the home setting
J Nurs Care Qual
 , 
2005
, vol. 
20
 (pg. 
349
-
55
)
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
, vol. 
24
 (pg. 
101
-
22
)
Franklin
M
Using patient safety science to explore strategies for improving safety in intravenous medication administration
J Vasc Access
 , 
2006
, vol. 
11
 (pg. 
157
-
60
)
Fletcher
PC
Hirdes
JP
Risk factors for falling among community-based seniors using home care services
J Gerontol A Biol Sci Med Sci
 , 
2002
, vol. 
57
 (pg. 
M504
-
M510
)
Scott
VJ
Votova
K
Gallagher
E
Falls prevention training for community health workers: strategies and actions for independent living (SAIL)
J Gerontol Nurs
 , 
2006
, vol. 
32
 (pg. 
48
-
56
)
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
, vol. 
17
 (pg. 
467
-
80
)
Gallagher
B
Corbett
E
Freeman
L
, et al.  . 
A fall prevention program for the home environment
Home Care Provid
 , 
2001
, vol. 
6
 (pg. 
157
-
63
)
Axelsson
J
Elmstahl
S
Home care aides in the administration of medication
Int J Qual Health Care
 , 
2004
, vol. 
16
 (pg. 
237
-
43
)
Boling
PA
The challenging problem of care transitions in home health care
Caring
 , 
2006
, vol. 
25
 (pg. 
24
-
6
)
Gray
SL
Mahoney
JE
Blough
DK
Adverse drug events in elderly patients receiving home health services following hospital discharge
Ann Pharmacother
 , 
1999
, vol. 
33
 (pg. 
1147
-
53
)
Benson
J
Incident reporting: a vital link to organizational performance
Home Healthc Nurse Manag
 , 
2000
, vol. 
4
 (pg. 
6
-
10
)
Bruno
L
Ahrens
J
Research.The importance of screening for depression in home care patients
Caring
 , 
2003
, vol. 
22
 (pg. 
54
-
8
)
Scharpf
TP
Functional status and quality in home health care
Ph.D. thesis
 , 
2005
Case Western Reserve University
 
151
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
, vol. 
24
 (pg. 
87
-
99
)
Seals
AB
Duffy
VG
Toward development of a computer-based methodology for evaluating and reducing medication administration errors
Ergonomics
 , 
2005
, vol. 
48
 (pg. 
1151
-
68
)
Cowley
EP
Assessing and preventing medication errors in home care
Home Health Care Consult
 , 
2000
, vol. 
7
 (pg. 
33
-
40
)
Clause
SL
Triller
DM
Problem with nebulized medications in a home health care patient. Am
J Health Syst Pharm
 , 
2002
, vol. 
59
 (pg. 
1462
-
3
)
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
, vol. 
60
 (pg. 
905
-
10
)
Salvatore
T
Elder suicide: a preventable tragedy
Caring
 , 
2000
, vol. 
19
 (pg. 
34
-
7
)
Zeppetella
G
How do terminally ill patients at home take their medication?
Palliat Med
 , 
1999
, vol. 
13
 (pg. 
469
-
75
)
Ellenbecker
CH
Frazier
SC
Verney
S
Nurses' observations and experiences of problems and adverse effects of medication management in home care
Geriatr Nurs
 , 
2004
, vol. 
25
 (pg. 
164
-
70
)
Montalto
M
How safe is hospital-in-the-home care?
Med J Aust
 , 
1998
, vol. 
168
 (pg. 
277
-
80
)
Dimond
B
Intravenous therapy: duty of care and liability
Br J Nurs
 , 
2006
, vol. 
15
 (pg. 
392
-
3
)
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
, vol. 
21
 (pg. 
13
-
5
)
Odegard
S
Andersson
DK
Knowledge of diabetes among personnel in home-based care: how does it relate to medical mishaps?
J Nurs Manag
 , 
2001
, vol. 
9
 (pg. 
107
-
14
)
Helleso
R
Lorensen
M
Sorensen
L
Challenging the information gap—the patients transfer from hospital to home health care
Int J Med Inform
 , 
2004
, vol. 
73
 (pg. 
569
-
80
)
Home health: court blames nurses, in part, for patient's downhill course
Legal Eagle Eye Newsl Nursing Profession
 , 
2007
, vol. 
15
 pg. 
6
 
ufseeser-Weiss
MR
Ondeck
DA
Medication use risk management: hospital meets home care
Home Health Care Manag Pract
 , 
2000
, vol. 
12
 (pg. 
5
-
10
)
Cohen
H
Proulx
S
Preventing medication errors in home care: applying system and process improvements
Infusion
 , 
1998
, vol. 
4
 (pg. 
46
-
50
)
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
, vol. 
163
 (pg. 
2716
-
24
)
Hamme
M
Medication management educational tools for improving target outcomes: any emergent care
Home Healthc Nurse
 , 
2006
, vol. 
24
 (pg. 
80
-
6
)
Aufseeser-Weiss
MR
Ondeck
DA
Medication use risk management: hospital meets home care
J Nurs Care Qual
 , 
2001
, vol. 
15
 (pg. 
50
-
7
)
Wilder
GL
Medication safety in home infusion care
J Infus Nurs
 , 
2003
, vol. 
26
 (pg. 
311
-
8
)
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
, vol. 
20
 pg. 
404
 
Woomer
N
Long
CO
Anderson
C
, et al.  . 
Benchmarking in home health care: a collaborative approach
Caring
 , 
1999
, vol. 
18
 (pg. 
22
-
8
)
Feldman
PH
Bridges
J
Peng
T
Team structure and adverse events in home health care
Med Care
 , 
2007
, vol. 
45
 (pg. 
553
-
61
)
Ventilator patient: family saw patient in distress, but cannot sue
Legal Eagle Eye Newsl Nursing Profession
 , 
2004
, vol. 
12
 pg. 
7
 
Pai
MP
Mercier
RC
Koster
SA
Epidemiology of vancomycin-induced neutropenia in patients receiving home intravenous infusion therapy
Ann Pharmacother
 , 
2006
, vol. 
40
 (pg. 
224
-
8
)
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
, vol. 
27
 (pg. 
425
-
30
)
Malani
PN
DePestel
DD
Riddell
IVJ
, et al.  . 
Experience with community-based amphotericin B infusion therapy
Pharmacotherapy
 , 
2005
, vol. 
25
 (pg. 
690
-
7
)
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
, vol. 
21
 (pg. 
33
-
8
)
Chenoweth
CE
Washer
LL
Obeyesekera
K
, et al.  . 
Ventilator-associated pneumonia in the home care setting
Infect Control Hosp Epidemiol
 , 
2007
, vol. 
28
 (pg. 
910
-
5
)
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
, vol. 
97
 (pg. 
869
-
73
)
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
, vol. 
8
 (pg. 
233
-
6
)
Feldman
PH
McDonald
M
Rosati
RJ
, et al.  . 
Exploring the utility of automated drug alerts in home healthcare
J Healthc Qual
 , 
2006
, vol. 
28
 (pg. 
29
-
40
)
Weick-Brady
MD
Lazerow
RN
Medical devices: promoting a safe migration into the home
Home Healthc Nurse
 , 
2006
, vol. 
24
 (pg. 
298
-
304
)
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
, vol. 
57
 (pg. 
332
-
7
)
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
, vol. 
11
 (pg. 
786
-
9
)
Fortinsky
RH
Madigan
EA
Sheehan
TJ
, et al.  . 
Risk factors for hospitalization among medicare home care patients
West J Nurs Res
 , 
2006
, vol. 
28
 (pg. 
902
-
17
)
Joint Commission offers lessons in home care
Healthc Risk Manag
 , 
2001
, vol. 
23
 (pg. 
55
-
6
)
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
, vol. 
13
 (pg. 
267
-
71
)
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
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)
Gill
TM
Baker
DI
Gottschalk
M
, et al.  . 
A prehabilitation program for physically frail community-living older persons
Arch Phys Med Rehabil
 , 
2003
, vol. 
84
 (pg. 
394
-
404
)
Cox
AM
Malani
PN
Wiseman
SW
, et al.  . 
Home intravenous antimicrobial infusion therapy: a viable option in older adults
J Amer Geriatr Soc
 , 
2007
, vol. 
55
 (pg. 
645
-
50
)
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
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
, vol. 
29
 (pg. 
408
-
12
)
Rosenheimer
L
Embry
FC
Sanford
J
, et al.  . 
Infection surveillance in home care: device-related incidence rates
Am J Infect Control
 , 
1998
, vol. 
26
 (pg. 
359
-
63
)
Shah
SS
Manning
ML
Leahy
E
, et al.  . 
Central venous catheter-associated bloodstream infections in pediatric oncology home care
Infect Control Hosp Epidemiol
 , 
2002
, vol. 
23
 (pg. 
99
-
101
)
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
, vol. 
179
 (pg. 
442
-
8
)
Bergquist
S
Frantz
R
Braden scale: validity in community-based older adults receiving home health care
Appl Nurs Res
 , 
2001
, vol. 
14
 (pg. 
36
-
43
)