1 Curtis W. and Ann H. Long Department of Family and Community Medicine, School of Medicine, University of Missouri , Columbia, Missouri.
J Palliat Med. 2013 Dec;16(12):1561-7. doi: 10.1089/jpm.2013.0104. Epub 2013 Oct 26.
In the home hospice environment, issues arise every day presenting challenges to the safety, care, and quality of the dying experience. The literature pertaining to the safety challenges in this environment is limited.
The study explored two research questions; 1) What types of patient safety incidents occur in the home hospice setting? 2) How many of these incidents are recognized by the hospice staff and/or the patient or caregiver as a patient safety incident?
Video-recordings of hospice interdisciplinary team case conferences were reviewed and coded for patient safety incidents. Patient safety incidents were defined as any event or circumstance that could have resulted or did result in unnecessary harm to the patient or caregiver, or that could have resulted or did result in a negative impact on the quality of the dying experience for the patient. Codes for categories of patient safety incidents were based on the International Classification for Patient Safety.
SETTING/PARTICIPANTS: The setting for the study included two rural hospice programs in one Midwestern state in the United States. One hospice team had two separately functioning teams, the second hospice had three teams.
54 video-recordings were reviewed and coded. Patient safety incidents were identified that involved issues in clinical process, medications, falls, family or caregiving, procedural problems, documentation, psychosocial issues, administrative challenges and accidents.
This study distinguishes categories of patient safety events that occur in home hospice care. Although the scope and definition of potential patient safety incidents in hospice is unique, the events observed in this study are similar to those observed with in other settings. This study identifies an operating definition and a potential classification for further research on patient safety incidents in hospice. Further research and consensus building of the definition of patient safety incidents and patient safety incidents in this setting is recommended.
在家庭临终关怀环境中，每天都会出现各种问题，给患者的安全、护理和临终体验质量带来挑战。这方面的文献资料有限。
本研究探讨了两个研究问题；1）家庭临终关怀环境中发生了哪些类型的患者安全事件？2）这些事件中有多少被临终关怀工作人员和/或患者或护理人员识别为患者安全事件？
对临终关怀跨学科团队病例会议的视频记录进行了审查，并对患者安全事件进行了编码。患者安全事件被定义为任何可能导致或已经导致患者或护理人员不必要伤害的事件或情况，或者可能对患者的临终体验质量产生负面影响的事件或情况。患者安全事件类别的代码基于国际患者安全分类。
设置/参与者：该研究的设置包括美国中西部一个州的两个农村临终关怀项目。一个临终关怀团队有两个独立运作的团队，第二个临终关怀团队有三个团队。
共审查了 54 个视频记录并进行了编码。确定了涉及临床流程、药物、跌倒、家庭或护理、程序问题、文件、心理社会问题、行政挑战和事故等问题的患者安全事件。
本研究区分了家庭临终关怀护理中发生的患者安全事件类别。尽管临终关怀中潜在患者安全事件的范围和定义是独特的，但本研究中观察到的事件与其他环境中观察到的事件相似。本研究确定了一个操作定义和一个潜在的分类，用于进一步研究临终关怀中的患者安全事件。建议进一步研究并就患者安全事件和该环境中的患者安全事件的定义达成共识。
