Only Part of the Healthcare System Has Been Addressed
Patient safety has evolved and developed in the context of hospital care. The understanding we have of the epidemiology of error and harm, the causes and contributory factors and the potential solutions are almost entirely hospital based. The concepts which guided the study of safety in hospitals remain relevant in primary and community care but new taxonomies and new approaches may be required in these more distributed forms of healthcare delivery (Brami and Amalberti 2010; Amalberti and Brami 2012).
Care provided in a person's home is an important context for healthcare delivery but patient safety in the home has not been addressed in a systematic manner. The home environment may pose substantial risks to patients, greater in some cases than in the hospital environment. Safety in the context of a patient's home care is likely to require different concepts, approaches and solutions to those developed in the hospital setting. This is because of the different environment, roles, responsibilities, standards, supervision and regulatory context in home care. Critical differences are that patients and carers are autonomous and are increasingly taking on professional roles; they rather than the professional become the potential source of medical error. Additionally, stressful and potentially hazardous conditions, such as poor lighting, mean that socio-economic conditions take on a much greater importance.
In both primary care and care at home the risks to patients are rather different from those in hospital, being much more concerned with omissions of care, failure to monitor over long time periods and lack of access to care. These areas have not traditionally fallen within the area of patient safety but are undoubtedly sources of potential harm to patients. The concept of the patient safety incident, and even of adverse events, breaks down in these settings or is at least stretched to its limit. Suppose, to take just one example, a patient is hospitalised after taking an incorrect dose of warfarin for 4 months. The admission to hospital could be viewed as an incident or a preventable adverse event. This description however hardly does justice to 4 months of increasing debility and ill health culminating in a hospital admission. In reality, the admission to hospital is the beginning of the recovery process and a sign that the healthcare system is at last meeting the needs of this patient. The episode needs to be seen not as an isolated incident but as an evolving and prolonged failure in the care provided to this person.