Exploring patient safety in home healthcare : a resilience engineering approach

Sammanfattning: 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 seven individual 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 phases and 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 used for 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 values against each other, between risks and patients’ and relatives’ autonomy and wishes. Other typical contradictory values were between collecting measurements for different quality registers (directives from policy-makers as a measure of quality 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 “deficiencies in 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” (Paper V).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, which forms 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 can be 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.