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I never did anything worth doing by accident, nor did any of my inventions come indirectly through accident, except the phonograph. No, when I have fully decided that a result is worth getting, I go about it, and make trial after trial, until it comes.

Thomas Edison

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. Safety in
home care is likely to require different concepts, approaches and solutions. Safety
in this context has however been barely addressed and yet care provided in the home
will soon become the most important context for healthcare delivery.
The term ‘home care’ can encompass a variety of residential settings in which
people are cared for by family, nurses and other professionals. In this chapter we use
the term in a more restricted way to refer to the care of people in their own home,
with varying degrees of informal and professional support. We focus on people with
illnesses, usually chronic conditions, who are either living independently or being
supported in their own homes by family or professional carers. Much healthcare is
already delivered in the patient’s home and this form of provision is growing rapidly. The benefi ts of home based care have been widely discussed, but the risks have
not been fully articulated. In this chapter we fi rst briefl y summarise the background
to the expansion of home care and then consider the nature and challenges for
patient safety and the strategies that might help us manage risk in the home.

The Hazards of Home Care: New Risks, New Challenges

In the last 20 years a series of studies have revealed the hazards of care in hospital.
In consequence we tend to assume that patients will be safer at home; this is no
doubt true for people who are relatively well, but may not be true for the frail and
vulnerable. Care at home could, in some circumstances, generate even more adverse
events than hospitals. The advancing age of the average patients at home and
increasing numbers of comorbidities and medications are all associated with
increased risk of experiencing a medication error or an adverse event (Lorincz et al.
2011 ). We cannot foresee all the potential hazards but studies are beginning to illuminate some of the dangers to patients and to carers.

Accidental Injury in the Home

Home is a more dangerous environment than most of us imagine. The leading
causes of unintentional home injury deaths are falls, poisoning, fi re and burns, airway obstruction, and drowning. Elderly residents are disproportionately affected,
accounting for more than 2.3 million home injuries and 7000 unintentional home
injury deaths annually in the United States (Gershon et al. 2012 ). People who are
both old and ill are likely to be still more vulnerable to accidental injury. Risk factors include decline in physical or mental function, unsafe behaviours (such as
smoking), living alone and health care management factors such as polypharmacy
and lack of medication review (Doran et al. 2009 ).

Adverse Events in Home Care

An early study of home care in Canada found that 5.5 % of 279 home care clients
suffered adverse events; injurious falls accounted for nearly half, followed by
medication- related events, pressure ulcers and psychological harm (Johnson 2005 ).
Two recent studies, one conducted in the USA (Madigan 2007 ) and the other in
Canada (Sears et al. 2013 ), found that 13 % of home care patients experienced an
adverse event. Larger estimates based on expert chart review of 1200 patients discharged in 2009–2010 in Canada showed a rate of 4.4 % adverse events (Blais et al.
2013 ). The most frequent were injuries from falls, wound infections, behavioural or
mental health problems and adverse outcomes from medication errors. The number
of comorbid conditions and the level of dependency greatly increased the risk of
experiencing an adverse event. Patients can also be victims of abuse from family
members, which might not always be readily apparent to care providers (MacDonald
et al. 2011 ).
Adverse Drug Events

Adverse drug events have been the most studied safety issue in the home. Some studies have found that as many as 5 % of patients who were receiving nursing support at
home had suffered from an adverse drug event of some kind during the previous
week (Ellenbecker et al. 2004 ) and 25 % in the past 3 months (Sorensen et al. 2005 ).
These problems are often due to poor communication between hospital staff, patients
and their doctors in primary care (Ellenbecker et al. 2004 ). Few studies directly
assess medication error caused by patients and family members, though models of
human error should be equally applicable to patients and informal caregivers as to
professionals (Barber 2002 ). In an Australian study, 35 % of readmissions were associated with incorrect drug administration at home. Those who had large stocks of
medication at home were more exposed to adverse events (Sorensen et al. 2005 ). The
majority of patients receiving home care services are taking more than fi ve prescription drugs and over a third of patients are taking medications in ways that deviated
from the prescribed medication regimen (Ellenbecker et al. 2004 ).
Risk to Family and Other Care Givers
Unpaid carers are particularly vulnerable to stress, long term burn out and ill health.
Although health care aides play a role in giving assistance, the range of tasks falling
to carers is considerable: assistance with eating, moving, washing, cleaning, connecting systems, improvising when systems fail, making decision on drug doses
adjustments and responding to symptoms, often without any external advice or
guidance.
Caring for a person with dementia is a full time occupation with no restriction on
hours or oversight from the occupational health and safety regulations which protect
8 Safety Strategies for Care in the Home

professionals. Care at home is viewed positively as reducing the burden on the
healthcare system; it might be more accurate to say that the burden is being transferred to the family and the patient themselves. The safety of professional care givers is also of concern, in that they are often sole workers who need to venture into
dangerous areas to care for people who may themselves be dangerous. Increasing
use of home care is bound to increase these risks, although these can be mitigated
with proper support and appropriate technologies