The benefits of providing healthcare in the home, for both minor and more serious conditions, are undoubted. As homecare becomes more complex however there will be a correspondingly greater risk of adverse events and therefore a need to anticipate and plan for a response to those events and mitigate their effects. In a hospital the rapid initiation of a remedial response to physical harm is part of routine clinical practice and we have previously discussed the need for psychological support for patients and staff. Mitigation strategies in the home will need to include consideration of both the psychological impact and preparation for an emergency response. In the event of a crisis the patient will need access to the right person at the right time; a capacity for rapid rehospitalisation whenever needed will be critical, especially at nights and week-ends.

The Responsibilities of Carers

The recognition that staff can be seriously affected by the role they have played in an error or harmful event has been a very important step forward, although programmes for supporting staff are still rare. In the home patients and carers are increasingly taking on professional roles and therefore they too may make serious and consequential errors. If a family member makes an error they have all the burden of responsibility that a professional bears combined with the terrible experience of harming someone close to them. Interviews with carers suggest that the responsibility for giving powerful medications can become burdensome both because of the time commitment and anxiety about making mistakes; many carers do not receive clear guidance about medication, leading to omissions, incorrect doses, anxiety and confusion which are often not recognised by health professionals (While et al. 2013). Relatives of people near the end of their lives face the additional worry about hastening death through improper use of medication (Payne et al. 2014). The blurring of boundaries between family carers and professionals is difficult for all concerned particularly towards the end of a person's life. As well as providing support and training to carers, we will also have to consider how to provide support in the event of a serious error, an issue which has currently not been addressed at all.

Mitigation Strategies in Home Haemodialysis

Home haemodialysis is hugely beneficial for patients in that dialysis at home preserves independence and autonomy and reduces dependence on the hospital. Patients and carers can become apprehensive about performing such a complex set of tasks and fearful about the potential for dialysis related emergencies (Pauly et al. 2015). Home dialysis is generally a very safe procedure but a number of deaths due to error have been recorded, such as a man who died from exsanguination after he connected a saline bag to a blood circuit (Allcock et al. 2012). In the early stages of home dialysis patients report frequent mistakes while they learn the procedures and develop their own personal safety strategies, such as ensuring that there are no interruptions and ensuring that help is on hand in the event of problems (Rajkomar et al. 2014).

Established haemodialysis units provide training and prepare patients and carers very carefully for home dialysis procedures. Instilling a culture of safety without unduly alarming the patient, ongoing vigilance from both patients and professionals and ongoing support are critical. In addition Pauly and colleagues (2015) suggest that it is necessary to develop safety strategies to mitigate the risk of adverse events, which include the anticipation and preparation for any adverse events that do occur. They set out a series of measures which includes the provision of an explanatory letter for a patient to take to an emergency department, ensuring the patient is fully briefed in emergency procedures, and a full set of procedures for staff to initiate to respond and learn from any events that do occur. The most important lesson from their account is the preparation that they provide for patients and carers includes an explicit and comprehensive set of safety strategies as part of the basic programme.

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