Influences on Safety of Healthcare Delivered in the Home

Patient safety at home cannot be conceptualized or managed in the same way as patient safety in hospital because of the very different environment, roles, responsibilities, standards, supervision and regulatory context of home care. People are cared for in their homes and within the context of their family and the daily lives of all concerned. The quality and safety of care is influenced by the nature of formal service provision and the characteristics of the client receiving care, the physical environment and the availability of family and other carers (Hirdes et al. 2004; Lang et al. 2008b). We outline some of the main factors that will need to be assessed and understood when designing safe home care services.

Socio-economic Conditions Take on a Much Greater Importance

In an institutional setting, patients receive a certain standard of care regardless of their socioeconomic or cognitive status. In contrast, resources and environment of the home will vary hugely by socio-economic status. Wealthier people will be able to have a much higher standard of home care; they will have space for separate 'hospital' accommodation, paid support workers, leisure, better nutrition, less disruption of family life, and a higher probability that relatives can 'work' as carers. If a reasonable standard is to be achieved in poorer homes specific resources would have to be allocated to poorer families and to supporting the medical professionals in charge of those patients at higher social risk.

The elderly and disabled can be supported in their own environment 24 h a day by numerous 'smart' devices (Anker et al. 2011). Advances in telecommunication technologies have created new opportunities to provide tele medical care as an adjunct to medical management of patients. Feeling safer comes with a cost however, and that cost is often paid by the family. Contemporary homes are not typically designed or envisioned as places where complex or long-term health care is provided. The plethora of intrusive equipment, combined with the continual presence of carers, can make the person feel that their home is no longer a home.

The Home Environment as Risk Factor

The role of design in either degrading or promoting patient safety is increasingly understood. New hospitals may now be built with safety in mind, using good design to reduce equipment problems, assist infection control and reduce errors of all kinds (Reiling 2006). Once we move into the home, this hard won gain in understanding is largely lost. Stressful and potentially hazardous conditions, such as poor lighting, excessive clutter, presence of vermin, and aggressive family members, inadequate or unavailable sharps containers, and lack of readily accessible personal protective equipment, can directly or indirectly greatly increase the risk of adverse events in this population (Gershon et al. 2009, 2012).

In some homes performing clean or sterile procedures may be almost impossible. There is also the possibility that home care staff may transmit infections between homes, particularly when patients have been discharged after contacting MRSA or C-difficile. Hand washing provides some protection but cleaning equipment in the home environment is challenging (MacDonald et al. 2011).

The Household safety survey checklist (Table 8.1) includes the checking of fire and electrical risks, ergonomic (falls hazards), biological (unsanitary conditions), chemical, and other problems such as noise, temperature, poor security and violence. Additional items address various patient characteristics that influence safety. These include age, sex, health status, ability to walk without help, number of people in the household, daily medication, methods patients use to keep track of medications, presence of any medication in the home that patients no longer take, hearing aid use and the use of durable medical equipment and safety devices.

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