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Home > RNJ > 2011 > May/June > Home Health Nurses’ Perceived Care Errors

Home Health Nurses’ Perceived Care Errors
Said Absulem, PhD RN • Heather Hardin, RN

The Institute of Medicine (IOM) estimates that every year 44,000 to 98,000 people die due to errors in hospitals, costing approximately $37.6 billion each year (2000). However, limited data are available detailing the extent of healthcare errors outside of hospitals. A cross-sectional study was conducted to assess how home health nurses perceive and deal with errors. A convenience sample of home health agencies (N = 33) located in a Southeastern state participated in the study. Packets containing sealed surveys, a flier, and a description of the study were mailed to the nurses. Nurses were asked to complete a survey about their most significant care error and how they responded. Results from the study on home health nurses’ perceptions (N = 203) indicate that the perceived care errors were medication (40%), laboratory (15.5%), wound care (6.5%), scheduling and wrong patient visits (6%), teaching-care errors (5%), and needle sticks (1%). Medication errors remain the most commonly occurring error in the home healthcare area.

Home Healthcare Errors

Since the release of the Institute of Medicine’s (IOM) report on healthcare errors in late 2000, public and professional attention has been directed to reducing healthcare errors and their associated costs. Leading healthcare organizations, such as the Agency for Health Research & Quality (AHRQ), Center for Patient Safety (CPS), and Centers for Medicare and Medicaid Services (CMS), have invested many efforts to improve patient safety, primarily in hospital settings (Bates et al., 1995; Brenan et al., 1991; Kumar & Steinebach, 2008; Leape et al., 1991; Nuckols, Bell, Paddock, & Hilborne, 2008; Thomas et al., 2000). The number of older adult Americans accounts for 20% of the nation’s population (Jones, 2002) and is expected to reach 71 million in the year 2030. Concurrent to the growth of the elderly population is the growth of Medicaid expenditures—from $54.7 billion in 2007 to $136.5 billion in 2017 (Congressional Budget Office, 2007). In addition, the need for healthcare services provided in the home setting has increased, resulting in an increased potential for care errors (Ahren, 2003; Kovner, Menezes, & Goldberg, 2005). Given the level of national concern about reducing healthcare errors, there is a need to explore the incidence and types of errors committed by rehabilitation nurses, including home healthcare nurses.

There are many definitions of healthcare errors. This study used Leape’s (2006b) definition, which defines healthcare errors as “an unintended act (either of omission or commission) or as an act that does not achieve its intended outcome” (p. 3). This definition provides an umbrella that incorporates all types of nursing care errors. Healthcare errors in hospitals account for roughly 44,000 to 98,000 deaths annually (IOM, 2000). The Quality Interagency Coordination Taskforce (QuICT; 2000) considered medical care errors to be the sixth to eighth leading cause of death in the United States (IOM; QuICT). Medication errors account for an estimated 7,000 deaths per year, 16% higher than deaths from work-related injuries (Leape, 2006b). The cost of medical care errors has been estimated to be approximately $37.6 billion each year, $17 billion (45%) of which is attributed to preventable healthcare errors (IOM).

The increased longevity of the U.S. population and the increased need for care that has traditionally been provided by nurses for older adults has put added pressure on the healthcare delivery system (Robert Wood Johnson Foundation, 2008). The shortage of home health registered nurses is expected to worsen (U.S. Department of Health and Human Services, 2002), and the need for full-time home health registered nurses to care for the aging population will more than double by the year 2020. The patient load per nurse has increased, which increases the likelihood of patients dying within 30 days of admission, increases the odds of failure to rescue, and decreases job satisfaction (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).

Most research regarding healthcare errors focuses on errors occurring within hospitals (Bates et al., 1995; Brenan et al., 1991; Kumar & Steinebach, 2008; Leape et al., 1991; Nuckols et al., 2008; Thomas et al., 2000). Unfortunately, little is known about healthcare errors that occur outside of hospitals, especially the extent of healthcare errors in home health care (Ahren, 2003; Ellenbecker, Frazier, & Verney, 2004; Foster, Murff, Peterson, Gandhi, & Bates, 2003; Kovner, Menezes, & Goldberg, 2005; Madigan, 2007; Mager, 2007; Meredith et al., 2001; Sorensen, Stokes, Purdie, Woodward, & Roberts, 2005). The majority of patients in home healthcare are older adults. Because older adults are more physiologically and psychologically fragile, home healthcare errors can have a greater negative impact on their health than on other patients. Home health care is a growing segment in the health industry in the United States, so it is important to determine types of care errors in this segment of health care.

Purpose

The purpose of this study was to assess how home health nurses and agencies perceive and deal with healthcare errors in their practice settings. The specific aims were to (1) explore home health nurses’ response to questions about patient safety, (2) examine what home health nurses perceive as types of care errors in home health, and (3) examine how home health agencies deal with care errors.

Method

Study Design

A cross-sectional survey with a convenience sample design was used to explore home health nurses’ perceptions of healthcare errors and how agencies deal with healthcare errors.

Absulem Table 1Setting and Sample

This study was conducted in a Southeastern state. All of the state’s home health agency directors (N = 104) were contacted, resulting in a 32% (33 agencies) positive response rate. Table 1 shows the range of responses we received from the directors. All agency directors who agreed to participate in the study provided the number of nurses in each agency. Institutional review board (IRB) approval was obtained.

Procedure

Packets containing sealed envelopes were sent to every nurse employed at the agency, along with the study description and a flier to be posted in the agency. Each sealed envelope contained the survey, a self-addressed and stamped return envelope, and $2. The clinical director explained the survey to the nurses and read the study description in the regular home health agency staff meetings. The study description included an assurance, typed in large typeface, that survey responses were completely anonymous and confidential, and neither individual survey information nor single-agency information would be provided to anyone. Reminder cards were sent to all home health nurses at each agency. Approximately 15–20 minutes were required to complete the survey.

Survey Design

The following instruments were used in the study. A sociodemographic form was developed by the researcher to collect information about nurses’ education and experience. An additional survey was developed by the researcher to evaluate home health nurses’ knowledge and response to questions about the national patient safety movement. This survey was placed in the front of the questionnaire so that nurses who did not want to answer questions about their experience with care errors could answer questions about the patient safety movement. Finally, a modified Wu, Folkman, McPhee, and Lo (1991) care errors survey was included. The medical care errors survey developed by Wu and colleagues (1991, 1993) was modified by the researchers to assess home health nurses’ care errors and responses related to patient safety in this study. This survey was modified to fit the home health setting by the researchers, home health quality improvement experts, nurse administrators from the state home health association, quality improvement staff from a local home health agency, five nurse researchers and professors, a professor of statistics, and a methodologist. The methodologist was an expert in outcomes quality research and an expert in survey development. The word “physicians” was replaced with “home health” and “nurses” as appropriate. Similar to the Wu and colleagues’ hospital survey, the modified survey addressed the following areas: (a) type and severity of healthcare errors, (b) description of healthcare error, (c) circumstances in which the healthcare error occurred, (d) causes of the healthcare error, and (e) the institutional responses to the healthcare error event. The Likert scale for causes of healthcare errors and judgmental institutional responses ranged from 1 for strongly disagree to 4 for strongly agree. Each nurse was asked to write a paragraph describing a significant care error in which she or he had been involved. Nurses were encouraged to write their comments following categorical and Likert-scale questions.

The hospital survey researchers tested the survey with a sample of 254 internal medicine residents in hospitals and tertiary care facilities that had more than 500 beds (Wu et al., 1991, 1993). Not only did the researchers conduct factor analysis to group items into meaningful scales, but also they used group consensus. An overall score was obtained for each scale by adding responses to the items it included. Three scales were used to describe the causes of the care errors: case complexity (four items), inexperience (three items), and job overload (two items). Responsibility for the care error was assessed using a three-item scale. The degree to which the institutional response was judgmental was measured with two items.

The hospital medical care errors survey means, standard deviations (SD), and internal consistency reliability coefficients as reported by Wu and colleagues (1991) ranged between .50 and .82. Internal consistency reliability coefficient for this study and for the judgmental institution response scale was .69 with a mean of 2.5 (SD = 1.7). The difficulty and sensitivity of conducting studies about healthcare errors in home health agencies will affect reliability scores of scales used in such studies.

Analysis of Data

The researcher collected descriptive statistics such as frequencies, percentages, ranges, and means for demographic questions and all items in the scales. Narrative responses to open-ended questions about types of healthcare errors were analyzed using a coding scheme to group all reported errors into final exclusive categories. A simple content analysis technique was used to analyze the nurses’ open-ended answers. The unit of analysis included the respondents’ words, short phrases, sentences, sentence fragments, paragraphs, pictures, symbols, and ideas (Creswell, 2006). The verbatim words and phrases were sorted into themes and a manifest coding scheme was developed by counting the frequency of the verbatim themes. Manifest coding the items helped ensure intercoder reliability (Krippendorff, 2003). The content analysis procedure was repeated and confirmed by another analyst. Both analysts then reviewed their observations together and resolved the minor discrepancies until there was a final consensus.

Results

Agency Characteristics

The home health agencies (N = 33) that participated in the study served more than one geographic area. Geographical areas were urban if the agency served a city or town, suburban when the agency served the suburbs of a city or town, and rural when the agency served a country area. The majority of the participating home health agencies served rural areas (88%). More nonprofit home health agencies (76%, 25 agencies) than for-profit agencies (24%, 8 agencies) joined the study.

Participating Nurses Characteristics

The researcher mailed 381 surveys to the 33 agencies, resulting in a 53% (203 surveys) response rate. Twenty-three nurses (11%) did not answer the question about the type of healthcare error in which they were involved, while 32 nurses (10%) responded that they did not make healthcare errors.

Nurses’ years of experience ranged from 1–42 years, with a mean of 13 years (n = 103, SD = 9.4 years). One hundred and eight nurses in the study had earned an associate degree in nursing (53%) and 57 nurses were baccalaureate prepared (28%). Eighty-five percent of the nurses who participated in the study worked full time (n = 172), while 12% worked as part-time nurses (n = 24).

The Patient Safety Movement

Out of the 203 responses, 87% (n = 176) of nurses agreed (moderately agree and strongly agree) that home health nurses can improve patient safety, of which 50% strongly agreed. Eighty-six percent agreed that the home healthcare system can be improved to prevent care errors. Most respondents had read about patient safety (83%, n = 169), and many (53%, n = 107) reported that they had read about home healthcare errors. Eighty-eight respondents (43%) indicated they would like to be involved in the patient safety movement and activities. Fifty-four percent (n = 89) had attended different learning activities about patient safety and healthcare errors: 24 (12%) nurses attended lectures, 24 (12%) nurses participated in conferences, and 63 (31%) nurses attended meetings.

Perceived Types and Causes of Errors

The home health nurses completed an open-ended question and wrote a description about their involvement in different types of healthcare errors, their causes, and the severity of the healthcare errors. Data analysis revealed that perceived healthcare errors in home health were medication (40%), laboratory errors (15.5%), wound care errors (6.5%), scheduling wrong patient visit (6%), teaching-care errors (5%), and needle stick (1%).

Simple content analysis of the data showed that medication errors ranked as the number one healthcare error among the home health nurses. In one case, a home health nurse wrote that she administered too much intravenous medication (overdose). The directions for administration were not in the doctor’s order. There were no side effects, and the patient tolerated the medication well. Another nurse wrote “I forgot a PM [evening] injection I was supposed to give, and did not remember until it woke me up in the middle of the night. Usually if you are running a little late, the patient will call, but they did not that time. I felt awful. You would not think you would forget someone you have been seeing twice a day for a long time.” In another example, the nurse wrote “pre-filled a medication, filling it for a week with placement of medication in the wrong space, thereby, patient took medication before meal instead of another medication.”

Laboratory errors ranked as the second most frequent perceived healthcare error. Laboratory errors included incorrectly performed tests, missed tests, and partially missed tests. In some cases, there was a need to restick the patient, and results of laboratory tests were not communicated or were filed without notifying the physician. For example, a nurse wrote:

I have ve never done any patient service error but several months ago I was to obtain labs on a patient, which were very specific and specifically ordered for that date. I drew the wrong laboratory for the patient, and I did the INR (International Normalized Ratio) test instead of basal metabolic panel test (BMP), and the patient was not even taking anticoagulants. The doctor wanted a BMP that day; I had to call the doctor that day and go back the next day and draw the required laboratory work.

Another nurse wrote that “I missed a laboratory by a day or two. The computer system is wonderful but only if you regularly check all areas of information and continue to keep an updated monthly schedule.”

Wound care errors accounted for 6.5% of healthcare errors. One nurse wrote that “I was in a hurry to cut an armband off a patient’s arm and did not have scissors, used a scalpel to cut a dressing off the patient’s hand. It cut the patient’s hand and resulted in three stitches. I was distressed. I almost quit my job.” In another wound care error, a nurse wrote the following:

Patient was sent home with a wound vacuum machine, but the hospital sent the patient with the wrong vacuum machine. I had never seen a wound vacuum before, and the patient had numerous wounds. I attached the vacuum to the wound at the artery shading because I heard the company representative saying that the machine was fine for this. I made an error and called the wound nurse the next day.

Scheduling and wrong patient visits accounted for 6% of healthcare errors. A nurse wrote that “duplicate visits were made in the same day.” Another nurse wrote:

I visited the wrong home. My patient was in the hospital and had an appendectomy, and I visited another patient who was expecting a home health nurse from another agency. They let me in. We started talking and I realized this was not my patient, and the patient was across the street from my patient and also was in a gown expecting another home health nurse. The error could have been severe if the patient's identity had not been clarified early on.

Teaching-care errors occurred in 5% of all reported healthcare errors and needle stick in 1% of healthcare errors. Examples of teaching errors were reported as “not instructing client to check weight daily.” Another example involved a nurse who “typed in the incorrect height on pulmonary function test, which increased the severity of the illness. Fortunately, the clinical treatment would not have been much different.”

Thirty nurses provided detailed data about the type of care error in response to the open-ended question and thus were eligible for content analysis. Content analysis showed that the perceived causes were communication (53.3%), documentation (36.7%), and lack of familiarity with the equipment (10%). Nurses also described being unfamiliar with equipment that was prescribed to patients who had been discharged from the hospital. One nurse was unable to operate a wound vacuum machine.

Description of the Error

Most nurses discovered the healthcare error after the error was completely made (62%, n = 104). Fewer reported discovering the healthcare error at the beginning of the occurrence of the care error (12%, n = 20), at the middle of the occurrence of the healthcare error (15%, n = 25), or at the end of the occurrence of the healthcare error (12%, n = 20). Participating nurses reported that the healthcare error, in many instances, occurred to their regularly assigned patients (54%, n = 90), while 37% reported that the healthcare error had occurred with an assigned patient of another nurse for whom they were covering. Seventy percent of the nurses discovered their own healthcare errors (n = 118). Other nursing members discovered 12% of the healthcare errors, while physicians discovered 4% of the errors, patients discovered 3% of the errors, the caregiver discovered 3%, and others discovered 4%.

Nurses reported that the healthcare error was related to a nursing procedure (21%), incomplete information (18%), incorrect information received by telephone (4%), and incorrect information received during a home visit (1.5%). Fourteen nurses (7%) reported that there was a communication problem with the patient due to the patient’s altered mental status.

Circumstances of the Error

The most frequent age group affected by healthcare errors were patients 66 years or older (43%, 88), followed by patients who were 56–65 years old (17%, 35) and patients who were 46–55 years old (10%, 21). Nurses reported that their patient life expectancy prior to the healthcare error was mostly greater than 1 year (69%, 139). Fourteen (7%) patients had a life expectancy of more than 6 months to 1 year, while 13 patients (6%) had more than 1 month to 6 months life expectancy. Only two patients (1%) had a life expectancy of less than 1 month.

Different outcomes were reported as a result of the healthcare errors in home health care. One patient (0.5%) may have died due to the healthcare error, three patients (1.5%) were hospitalized, and three patients (1.5%) visited the doctor due to the healthcare error. Other outcomes caused by the error included a change in therapy (3%, 6) and undergoing a specific procedure (2.5%, 5). The most commonly reported outcome was physical discomfort (8.4%, 17) followed by emotional distress (5.4%, 11).

Institutional Response

Home health nurses reported nonjudgmental agencies’ responses with a mean scale score of 1.5, showing a moderately disagreeing score with the judgmental agency scale. The number of nurses who strongly disagreed and moderately disagreed with the statement “the home health agency inhibited me from talking about the error” was 135 (66.5%), while the number of nurses who strongly disagreed and moderately disagreed with the item “overall, administration was judgmental about my error” was 128 (63%). The number of nurses who strongly agreed and moderately agreed with the statement “I received the emotional support I needed from the colleagues in the home health agency” was 126 (62.1%) and 124 (61.1%) for the statement “my colleagues tried to put my error in perspective.” Fifty-four (26.6%) of nurses disagreed (strongly and moderately) that the agency implemented system changes to prevent similar care errors.

One hundred twenty-four nurses reported that healthcare errors were discussed with the patient’s physician and 32 nurses described the discussion as informal. It was also reported that in 34% of the cases, the nurses’ role in the healthcare error became known in the agency. The patients or their families were told by the nurse about the healthcare error in 58% of the cases. A nurse commented:

I informed the patient that their physician had ordered a new dressing change technique and that with previous dressing change it was performed as originally ordered. As a result, no adverse reactions occurred, but with next dressing change technique the nurse would follow the new order from the physician. The patient verbalized understanding, and was not upset.

Another nurse explained:

I called the patient and informed him I had inadvertently obtained the wrong laboratory and I will notify the physician, who instructed me to return the next day and obtain the correct laboratory test. Patient response was “That’s okay, just come back tomorrow and get what you need.” Patient’s daughter was present and I asked to speak to her so she would also know I was coming since it was not a regular scheduled visit.

Absulem Table 2Discussion

Home health nurses showed positive thinking and attitudes toward the safety of their patients; most home health nurses agreed that they can increase and improve patient safety. Nurses provided suggested ways to reduce care errors in home health care (Table 2). In addition, many nurses agreed that the home healthcare system can be improved to prevent healthcare errors. Home health nurses read about patient safety, and many nurses’ readings were related to home health care. Most home health nurses wanted to be involved in the patient safety movement and activities.

The number one perceived healthcare error of home health nurses was medication errors, followed by laboratory errors, and then wound care errors. Scheduling and wrong patient visit accounted for 6% of errors. Teaching-care errors were found in 5% of all reported healthcare errors. Although the study was concerned with healthcare errors that affect patients, nurses reported needle stick (1%) as a healthcare care error that affects them. These findings support and are consistent with other studies of nurses’ healthcare errors. Medication errors were reported by Balas, Scott, and Rogers (2004) as the number one healthcare error in hospitals. Balas and colleagues also reported that procedural errors ranked as the second most reported healthcare error in a hospital setting. In Balas and colleagues’ study, nurses explained healthcare errors they made included delayed or missed nurses’ action, implementation of care, and other laboratory errors. However, in this study the researcher was able to break down healthcare errors into laboratory errors, wound care errors, scheduling wrong patient visit, and teaching-care errors. Further data analysis indicated the following as causes of healthcare errors: communication, documentation, and lack of familiarity with equipment. According to Balas and colleagues, transcription and charting are the fourth and third most common causes of healthcare errors, respectively.

This study confirms findings by Foster and colleagues (2003) that medication errors are the most prevalent care error, and other healthcare errors include laboratory and wound care errors. It also demonstrates that communication and documentation are relevant and contributing factors. The IOM (2000) suggested system change, reorganization of practice, and the development of shock-absorbent systems as possible ways to eliminate errors (IOM; Reason, 2008). Home health nurses practice in the home setting, which is full of disorganized environments, noise, distractions, and, at times, unanticipated guests. All of these factors make it difficult to conduct professional nursing care. Because of the nature of home health nurses’ work, it is impossible to eliminate or avoid all distractions. Integrating and using technology and computerized strategies, such as bar coding and computerized order entry programs, may help decrease and prevent communication problems that lead to healthcare care errors in the home health agencies.

Foster and colleagues (2003) found that ineffective communication contributed to many healthcare errors. Nurses reported that the healthcare error was related to a nursing procedure (21%), incomplete information (18%), or wrong information received by telephone (4%). A recent international study found that ineffective communication contributed to healthcare errors at the time of discharge from the hospital (Schoen et al., 2005). Many nurses reported that ineffective communication at the doctors’ office was a contributing factor to medication errors. Other communication issues were identified among nursing supervisors and nurses, as well as between nurses, especially when one nurse covered for another. Intervention studies are needed to improve communication between the home health nurse, nursing supervisor, the laboratory, and doctors’ offices. Computerized systems, electronic medical records, and secure e-mail communication can help decrease and eliminate communication problems.

Quality improvement efforts in the home health agency continue to address the documentation issues. Computerized systems, software, and computer notebooks have been used in many home health agencies. Effectiveness studies are needed to evaluate the use and cost of such systems. Lack of familiarity with equipment was reported as a cause of errors. Home health agency management and discharge planners need to coordinate and communicate regarding equipment when patients are being discharged from the hospital to home health nursing follow-up.

Many nurses reported that the home health agency inhibited them from talking about the error in the agency response survey. The item is not clear about what type of talking was prohibited. Because many nurses reported that their supervisors put the error in perspective and were supportive, we believe the nonprofessional staff talking or break-room talking was prohibited by the supervisors. In a positive culture, a healthcare error can be revealed to the management and dealt with professionally to prevent deterioration of the patient and make sure the error has been addressed. On the other hand, cultures of blame tolerate failure because it assumes that the nurse intended to commit the healthcare error and that she or he is the only person responsible for it (Leape, 2006b). In a patient safety culture, healthcare errors will be studied and analyzed, new strategies will be developed, and actions will be implemented to prevent such a care error.

Many nurses reported that they received the emotional support they needed from their colleagues in the home health agency and that colleagues tried to put the error in perspective. More nurses disagreed (strongly and moderately) that the agency implemented system changes to prevent similar care errors than agreed. Home care agencies have evidence-based procedures and policies that support patient safety issues. Home healthcare agencies are required to track and conduct root-cause analysis of care errors and implement system changes to prevent similar errors. There is a need to study the effectiveness of root-cause analysis and conducted system changes as a response to care errors in the home healthcare area.

Positive information was revealed about the response of many agencies and nurses regarding the patient’s and family’s right to know about the care error. Most home healthcare nurses respected the rights of patients and families to know about the care error. One nurse wrote:

I explained to the family what I did and discussed what to look for and call the home health agency. I discussed with my supervisor what had happened and filled out an incident report. I called the doctor from the patient’s home as soon as it happened. The patient was checked and gained a couple of home visits. The patient did not complain of any problems.

Limitations

Nurses reported healthcare errors that they made in their clinical area and the consequences of those healthcare errors. Many nurses reported that they believed they had not made any healthcare error. There is a difference between actual errors and perceived errors. Nurses may perceive that they never committed an error when they did make a healthcare error. “What we know about patient safety depends on how we gather information, on how and who determines that a patient has been injured by an error or other lapse in care” (Leape, 2008, p. 1). This study used a cross-sectional survey design with a convenience sample. In healthcare error studies, it is difficult to believe that any study design could capture every healthcare error, so the interpretation and generalizability of the findings of this study must be taken into account.

A pilot study did not help provide comments about the survey despite strong support from the administrators of participating home health agencies. The pilot study showed the difficulty of recruiting home health nurses, who were described by administrators as “overwhelmed with home care visits and paper work.” Vigorous recruitment techniques were used to help conduct this study. IRB modifications prevented linking data and removed any questions that could identify respondent agency or nurse to maintain anonymity and confidentiality. Few responding nurses provided comments in the allotted spaces that followed several questions in the survey; this limited the data of several questions to survey questions and items. For example, we were unable to identify patients’ diagnoses. The survey did not include items to assess care errors and communication within the interdisciplinary rehabilitation team.

Conclusion

Many studies have been conducted to examine medication errors in home health care in regard to patient compliance and behaviors (Ahrens, 2003; Ellenbecker et al., 2004; Foster et al., 2003; Kovner et al., 2005; Meredith et al. 2001; Sorensen et al., 2005). However, additional studies are needed to examine the issue from the perspectives of home health agencies and nursing practice. Nursing practice can be adjusted and modified to deal with home healthcare errors. Multiple studies found that the majority of healthcare errors that affect patient safety can be linked not to caregivers’ lack of skills or knowledge but to defective work design (IOM, 2000; Perrow, 1984). The reengineering of work design should focus on patient care delivery and analyze care processes, tasks, procedures, and work flow in the home care agency (Gingerich, & Ondeck, 1996). The goal of modifying work design is to develop a proficient and effective work flow that is high quality and safe for home healthcare patients. One example of improving work design includes developing effective clinical pathways for documentation in home health care.

Many of the findings of home healthcare error studies relate to patients’ behaviors and home environments. Many of these findings help make nurses aware of the causes of medication errors in the home, which can inform their work and the care they provide. Nurses are working to eliminate such factors as much as possible. There is an overlapping of healthcare error causes between nurses’ performance, patients’ behaviors, and the home environment. Healthcare errors occur during many steps of the care process, and there is no silver bullet that will eliminate care errors. The nurses, physical therapists, occupational therapists, and social workers constantly work together with every key player in the care process to prevent and eliminate healthcare errors. Nurses are often members of the policy and procedure committees in their home healthcare agencies. Healthcare teams frequently conduct staff meetings to assess ways to improve the delivery of quality health care through improving communication between the team and other healthcare organizations. They also work hard to keep up with the advancement of the health sciences, knowledge, and technology. Many home health agencies are using documentation on laptops for the healthcare team. The National Association for Home Care and Hospice addresses political home healthcare issues through its legislative action network and asks healthcare workers to write to their senators about the potential effects of healthcare reform on the quality and patient safety of home health care.

Home health nurses practice on their own in patients’ homes where no other healthcare workers are available to support them if they are missing pieces of information. Some studies have reported nurses using cell phones from patients’ homes to begin the care process and manage missing information about care (Ahren, 2003). The professional management of barriers to effective communication, documentation, and familiarity with equipment is of great importance to advancing patient safety and reducing healthcare errors in home health care. Rehabilitation nurses working in the home healthcare setting should advocate for the patient safety movement in their workplace by supporting effective work redesign and improved communication between members of the healthcare team.

Further nursing research studies should examine the ways in which teamwork is promoted in the workplace and communication is improved between healthcare team members. Financial pressure, publicly reported quality indicators, and home health managers are all moving home health toward improving patient safety and the quality of health care.

Authors’ Note

This study was conducted in completion of Said Absulem’s dissertation and was supported by the National Institute for Occupational Safety and Health Pilot Research Project Training Program of the University of Cincinnati Education and Research Center Grant #T42/CCT510420.

Acknowledgments

I would like to thank professor Julie Sebastian for her guidance and support and Dr. Barbra Speck, Hong Huynh, Robert Topp, and all the people and participants who had to be anonymous for their great assistance.

About the Authors

Said Absulem PhD RN, is an assistant professor at the University of Louisville School of Nursing in Louisville, KY. Address correspondence to skabus01@louisville.edu.

Heather Hardin, RN, is a PhD student at the University of Louisville School of Nursing in Louisville, KY.

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