1. Harrison, Margaret B RN PhD

Aim: This integrative study on safety in home care provides a synopsis of evidence in the Canadian and international literature. The objectives of this study were to: (i) develop/test a comprehensive search strategy to locate the literature on harmful incidents (previously called adverse events (AEs)) in the home care environment to track emerging evidence; (ii) determine what has been documented about AEs in the home care setting; and (iii) catalogue definitions of safety in home care by analysis of reported/published definitions.


Methods: The review was characterised by a process of mapping and categorising existing literature in practice, health services and policy literature. Methods included a thorough search strategy determined by time/scope constraints, quality assessment of study sets relevant to design and graphic/tabular representation of the synthesis. This multi-step, iterative process used an explicit search and retrieval strategy based on Cochrane and Joanna Briggs Institute methodologies. A modified Problem, Intervention, Comparison, Outcome template was used to design the search. To facilitate concept clarification, key definitions relevant to patient safety and AEs in home care were catalogued.


Results: Multiple runs on searches were performed for sensitivity and specificity using the Peer Review of Electronic Search Strategies methodology developed by the Canadian Agency for Drugs and Technologies in Health and additional other approaches. Ninety-two research studies published from 1993 to 2010 and representing 14 countries (the majority North American) met the inclusion criteria (i.e. addressing AEs within the context of home care). Studies varied in scope from one home healthcare agency/site to nationwide investigations that involved more than five million participants. Quantitative research methods included experimental, descriptive and retrospective designs. Qualitative research methods included focus groups, interviews and consensus workshops. The nature of AEs was categorised as types of patient injury/harm related to an AE, caregiver instigated injury/harm and organisational/services/staff injury/harm.


Conclusions: There is an emerging evidence base about safety in home care. A predominant theme was the lack of conceptual clarity with the terms patient safety and AEs in the home care environment. An important finding was that innovative strategies/tools appear in the grey or peer-review literature as quality initiatives with/without evaluation elements. Traditionally, we do not concentrate heavily on the grey literature, but to advance the field, it may be necessary to place more emphasis on this source. A glaring limitation was the paucity of research on the occurrence of AEs and a lack of quality of research that documents prevalence estimates/incidence rates. Interventional research to evaluate risk reduction strategies was very limited and will advance only when tracking and documentation of various AEs improves.


Article Content


The increasing demand for care delivered in the home is a growing concern in most developed countries. In Canada, for example, the demand for home care services nationally increased by 51% between 1997 and 2007, highlighting this shift in care for home-dwelling individuals within the Canadian healthcare system.1 A recent Auditor General's report2 indicates that some 600000 individuals receive home care services in Ontario alone.


Despite the growing demand for home care services and the recognition that adverse events (AEs) * occur in all areas of healthcare delivery,5 the majority of patient safety research and AE studies have focused primarily on institutional settings.6,7,8 This trend is now beginning to change; patient safety and AEs are receiving more attention among home care health policy decision makers and healthcare managers.5,9,10 Notably, a broader 'understanding of patient safety issues among home care clients',7 (p. 166) is developing.


Although many of the same risks and AEs exist in both institutional and home settings, the context of care delivered in the home is vastly different and often requires unique solutions specific to home care settings. Care delivered in institutions is typically structured and regulated by organisational rules and standards, whereas care delivered at home tends to be less structured and often unregulated.5,11 Most of the primary care provided to people in their homes is done either by licensed or unlicensed care providers, or a combination of both, with many services contracted to multiple care agencies that rarely meet to coordinate services.10,11 Such a diversity of care providers and conditions makes issues surrounding patient safety and AEs complex and difficult to capture. Added to this, patients' homes are not typically designed for the types of services and tasks that increasingly are required in today's complex healthcare environment.12


The varied and inconsistent number of personnel and diversity of services provided in the home setting is thought to potentially increase the occurrence of AEs in comparison with the more controlled and regulated institutional setting.9,11 Given the expanding reliance on home as a setting of care and the different and additional challenges there, a deeper understanding of the issues surrounding safety and AEs is a pressing issue. Complicating this is lack of consensus or consistency in the use of key definitions for AE and patient safety in home care. In a groundbreaking paper, Lang et al.13 call for clarification of the definition of patient safety in home care and for the provision of clearly articulated elements specific to the diversity of settings within the home care domain.


Aim and objectives

In this study, we sought to provide a current synopsis of available evidence on home care safety in Canadian and international literature. Specific objectives were to:


1. Develop and test a comprehensive search strategy to locate national and international evidence about the nature, prevalence, magnitude and incidence of AEs in home care settings from relevant healthcare and policy databases;


2. Determine what has been documented about AEs in the home care setting, with respect to: (i) prevalence, incidence and magnitude of AEs for those receiving home care; (ii) nature of AEs for those receiving home care (i.e. range of AE's, associated risks); and (iii) policies, practices and tools and their effectiveness that could reduce avoidable AEs for people receiving home care;


3. Catalogue the reported/published definitions found in this review of the peer-review and grey literature of safety in the home care environment.



The study received ethical approval from the University of Toronto Ethics Board and Queen's University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board.



We undertook a 'mapping review or systematic map' of the safety in home care literature,14 (p. 94). Arksey and O'Malley15 describe it as a type of scoping study were 'the aim is to map rapidly the key concepts [horizontal ellipsis] the main sources and types of evidence available [horizontal ellipsis] to examine the extent, range and nature of research activity'. In this classification of review types, the process of mapping and categorising the existing literature helps to identify gaps in the research. Methods used in this type of review include a thorough search strategy determined by time/scope constraints, no formal quality assessment of studies and a graphic or tabular representation of the synthesis. Analysis of the integrated material is intended to demonstrate key features, gaps and directions for further research. We adapted this process to generate a synopsis of the literature on safety in home care.


In a multi-step and iterative process, we used search and retrieval strategies based on the Cochrane Library16 and Joanna Briggs Institute methodologies.17 To facilitate the current understanding of safety and AE in home care, key definitions relevant to patient safety and AEs in home care were extracted in order to conduct a simple content analysis. Search strategies were designed to locate both published and unpublished studies using a comprehensive combination of keywords and subject headings. Given the major changes in health services plus the enhanced focus on quality and patient safety over the past two decades, the search start date was set at 1990. A modified Problem, Intervention, Comparison, Outcome template18 was created to design the search and develop the research questions for this review (Table 1).

Table 1 - Click to enlarge in new window Inclusion and exclusion criteria

Our preliminary search revealed numerous 'projects' papers typified by the following: tended to be under the rubric of quality improvement; performed at the point of care; and/or used research evaluative processes ranging in levels of formality.


Although not formal research, we decided to include these as 'emerging' evidence if they met the following criteria: (i) intervention(s) were described; (ii) a discernible evaluation method was apparent; and (iii) outcomes were identified where a formal programme is described that was designed with the objective of identifying AEs, decreasing rates or reducing their impact.


Our three-step approach19,20 to search the peer-review literature included the following: (i) initial limited search of MEDLINE and CINAHL where keywords and subject headings were harvested from the relevant articles; (ii) search using all identified keywords and subject headings conducted across all included databases; and (iii) hand search of reference lists of all identified reports and articles for additional studies not identified electronically. Twelve databases were included: CINAHL, MEDLINE, Embase, PsycINFO, AMED, Cochrane, Web of Science, Ageline, GlobalHealth, Social Sciences Abstracts, IBSS and Criminal Justice Abstracts. The search for unpublished studies included dissertation abstracts; sociological abstracts; conference proceedings; Scirus and Mednar. To be thorough, we searched for studies in all languages.


Search strategies were tested for sensitivity and specificity by a library scientist and methodologist using the Peer Review of Electronic Search Strategies methodology developed by the Canadian Agency for Drugs and Technologies in Health.21 In addition to the main search, we conducted four specific searches for the common AEs in home care recently identified by Masotti5 (pressure ulcers, other wounds and injuries, wound infection and community-acquired infections). Although these appear to be AEs, we located fewer articles than anticipated through the patient safety search strategy. It is possible that in some cases, these events had not been considered by the authors to be a patient safety issue.


Once the set of included papers was determined, a further sensitivity and specificity testing on the search strategy was undertaken. A subject analysis was performed to check the validity and appropriateness of the original search strategy and to determine what changes were appropriate for updating the search. Articles were also tracked backwards to determine which subject headings and keywords were used.


Article retrieval and assessment

Electronic searching resulted in lists of articles. All identified articles were screened by a primary reviewer on the basis of the abstract (or title if abstract was not available). Full reports were retrieved for all studies clearly meeting the inclusion criteria (Table 1) and for those where there was any doubt from the title and/or abstract information. From the initial total of 7044 citations, 14% (n=1016) were considered potentially relevant and were screened by full article. To validate the selection of citations according to inclusion/exclusion criteria, a set of 32 papers (3% of the 1016) was purposefully selected to represent a range of study designs. These were reviewed independently by two secondary reviewers. Reconciliation was performed by a third party with any differences resolved through reviewer panel discussion. This facilitated the refinement of the inclusion/exclusion criteria. For example, 'assisted living' facilities were initially not included. Assisted living services have been defined as 'a programme designed to assist frail or cognitively-impaired seniors who do not need 24h nursing care and can reside at home with support, but whose care requirements cannot be met solely on a scheduled visitation basis. Programmes provide a combination of personal support and homemaking services, security checks or reassurance services, and care coordination, around the clock, on a scheduled and as-needed basis.'22 However, studies were found that illustrated the importance of these settings regarding the prevalence of AEs in the context of home care delivery, particularly regarding care provided by unlicensed personnel. The inclusion criteria were therefore amended to take into account assisted-living facilities.


Further to the peer-reviewed literature, a purposeful search of the grey literature was conducted to identify further information from non-research sources. It included Canadian national and provincial websites of organisations, some North American and international organisations with interests in patient safety. Types of information included reports, descriptive material, policies, procedures, tools and guidelines. This phase of the study will be reported elsewhere.


Given the emergent nature of home care patient safety research, all available studies were included to broadly represent the current 'state of knowledge', and no studies were excluded based on study quality. A limited critical appraisal was done on sets of studies (e.g. prevalence/incidence group) to indicate the quality of the emerging research/evidence in specific areas.


Data extraction

Data from the publications were extracted by the primary reviewer and organised in a Microsoft Access database (Microsoft, Redmond, WA, USA). The approach was developed by adapting Joanna Briggs Institute23 templates for data extraction and included: author, context and study details (research type and design, study purpose, sample size and detail, and instruments used). Specific aspects relevant for this review, such as factors that contributed to safety and risk, incidence/prevalence of AEs, and intervention strategies were also detailed. A proportion check (15%) by a secondary reviewer examined extraction completeness and accuracy. Third-party reconciliation verified elements. Ideally, an independent second review would be used. However, the proportional quality check was used because the initial purpose of this review was to inform a larger Pan-Canadian initiative of primary studies and time constraints mandated that we complete this substantive review within a 6-month time frame. The proportional quality check involved tabulating the percentage of major elements correctly or incorrectly extracted with an a priori benchmark set at 70% or less which would trigger extraction of a further 10 studies to verify congruency. Using the structured abstract of each study, synoptic tables were constructed addressing each study objective. Subset tables (e.g. prevalence incidence and strategies) were created following the structure of the Cochrane 'characteristics of included studies' format.16


Definitions relevant to patient safety in home care were catalogued when found in the peer-review literature and recorded in the database, detailing author, year, country, context of definition and notations made if the definition was cited by other authors. For the purpose of this review, we used the definition provided by Masotti et al., in 2007, as it was the only definition for AEs to incorporate the word 'home care'. In this instance, AEs are defined as '[e]vents or occurrences, which become apparent during the delivery of home care services and which have a negative or potentially negative impact on: patient care, patient outcomes, family or support care, and resource utilization'24 (p. 63).



Search strategy development and testing

We faced many challenges in developing a comprehensive approach to searching for home care-based safety studies. With no Medical Subject Heading in MEDLINE/Pubmed for the concept 'patient safety', determining which criteria best matched our definition proved difficult. Added to this, patient safety issues were often not identified as such by the original authors, thus were not given subject headings or keywords related to this topic. This problem has been noted earlier by several authors,18,19 and our search strategy was devised using a combination of these authors' strategies.


Tracking backwards to determine the use of subject headings and keywords, the most commonly used subject headings to describe 'home care' were (number of articles): home care services (73), home care (Embase heading only) (55), home healthcare (25), home care services, hospital based (19) and home health agencies (16). The most commonly used subject headings to describe 'patient safety' were: risk (50), risk factors (49), pressure ulcer (39), medication errors (28) and safety (27). Two subject headings (risk and risk factors) were not included in our original search because an analysis of the number needed to read using these two subject headings revealed very large retrieval numbers. Inclusion of these subject headings in the initial search would have increased the number to be read by nearly 10-fold (from 9.77 to 94; i.e. for every one article we decided to include, the number of articles we would need to read (and eventually exclude) would increase from 9.77 to 94 articles). The magnitude of this increase was beyond the capacity of this scoping review. One of the most confounding issues was that many articles used subject headings or keywords of 'home care' but referred to care of the self at home, and thus did not match our inclusion criteria (Table 1). This distinction entailed a resource-intense aspect of reading >1000 full papers in order to compile our final dataset of studies.


Definitions of AE and patient safety

Early in this study, it became obvious that there was no consensus or standardisation of the terms 'AE' and 'patient safety'. As a result, a systematic effort was made to track the number and array of definitions. In the time frame (1991-2011), we tracked a total of 40 definitions for 'AE'. In one instance, an author provided two definitions and another provided three. Many of the definitions had minimal variation in wording, with a vast majority specifying the AE as occurring to a 'patient' or happening within the hospital context. The most commonly used definition was one endorsed by the Institute of Medicine; it was also cited by five different authors. This definition is medically focused and describes an AE as '[a]n injury resulting from a medical intervention and not due to the underlying condition of the patient. While all adverse events result from medical management, not all are preventable - i.e. not all are attributable to errors'25 (p. 4).


As mentioned earlier, Masotti24 (p. 63) provides the only published definition for AE which incorporates the word 'home care'. In this case, an AE was defined as '[e]vents or occurrences, which become apparent during the delivery of home care services and which have a negative or potentially negative impact on: patient care, patient outcomes, family or support care, and resource utilization'.


We found a total of 19 unique definitions of 'patient safety' in research papers published from 1995 to 2011. Patient safety was defined generally by many groups and individuals, including professional associations and researchers. Many of the definitions reflected 'the avoidance or minimisation of harm during healthcare delivery'. One of the most commonly used definitions was provided by the Institute of Medicine, also cited by three different authors. This definition describes patient safety as '[f]reedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur'25 (p. 23). A second definition, 'The identification, analysis and management of patient-related risks and incidents, in order to make patient care safer and minimize harm to patients'25 (p. 550), was also cited by three different authors.


Summary of the published literature on safety in home care

Our combined search strategies returned a total of 7044 citations (Fig. 1). From this set, we identified 92 unique studies (reported in 100 publications) that addressed AEs within the context of home care (Table 2). The primary reason for exclusion was that study participants were not receiving professional home care services. Of the papers focusing on home care, further exclusions were made because they were not research studies. Also, 34 studies that may have been included based on their English abstracts were excluded because the main papers were not in languages we could translate including: German (seven), Spanish (six), Norwegian (five), Danish (three), Japanese (three), Chinese (two), Dutch (two), Portuguese (two), Swedish (two) and Czechoslovakian (one). We had the ability to translate English, French or Italian but had no access to translation services in these other languages.

Figure 1 - Click to enlarge in new window Search decision tree for peer-reviewed literature (1990-2010).
Table 2 - Click to enlarge in new window Characteristics of studies included (

In the final analytical set (n=92), studies were published over an 18-year period (1993-2010) and represented 14 countries (as identified by the lead author) with the majority (n=63) being North American (Canada or the USA). Studies varied widely in scope from being focused on one home healthcare agency or site to nationwide investigations involving more than five million participants (Table 2).


Quantitative research designs were most common including 11 randomized controlled trials. The majority of the other designs were descriptive studies (Table 3), and retrospective methods were frequent (n=24). Qualitative research methods included focus groups, interviews and consensus workshops, with none of the studies describing a specific paradigm or research style (e.g. philosophic, documentary, historical).

Table 3 - Click to enlarge in new window Research method and design (

Secondary analysis was described in 20 studies. Of these, more than half (11 studies) used data from the same dataset, the Outcome and Assessment Information Set, and six studies used data from the Resident Assessment Instrument-Home Care database. Other databases included the Arizona Department of Health Services26 and the Food and Drug Administration database.27 A secondary analysis in another study28 examined the validity and reliability of a researcher-developed instrument, the Home-screen Scale.


Patient safety research in home care covered the spectrum of developmental categories (range: birth to >100 years). After assigning developmental groupings according to Statistics Canada's definition (0-14=child, 15-24=adolescent, 25-64=adult, and elders 65 and older), elders were the highest proportion (59.6%), and children, the least (1.9%). The focus of issues addressed by the studies included prevalence/incidence (38 studies), nature of AEs (72 studies), risk of AEs (24 studies), strategies to cope with AEs (11 studies) and benchmarking (six studies) (note the categories of focus are not mutually exclusive).


The majority of studies (33/38) were focused on specific AEs. Falls were the most commonly reported AE, and prevalence estimates ranged from 6.4 to 70.6%. Estimates for patients who fell multiple times ranged from 2.1 to 27.5%. The next most frequently reported were pressure ulcers with admission prevalence estimates ranging from 6.0 to 17.9%. Notably, three studies (Paquay et al.,29 Schwien et al.,30 Meehan et al.31) indicated the same estimate rate of 6.8% for pressure ulcers (sample sizes ranged from 2779 to 1941039). Medication errors, the third most commonly reported prevalence estimates, ranged from 7.6 to 69%.


Nature of AEs for those receiving home care

In qualitatively exploring the nature of AEs in the home care setting, there is emerging evidence about the range of events and associated risks. Seventy-two studies documented 44 different AEs (Table 4). Studies were catalogued according to three general categories: types of patient injury/harm related to an AE, unpaid caregiver-instigated injury/harm and injury/harm potentially resulting from organisational/services/staff issues (e.g. patient unprepared at discharge, discharged to the community needing special care) or resulting from AEs (e.g. emergency visits, hospitalisations, physician visits). AEs were extracted verbatim as described by study authors, and some of the AEs could be interpreted as contributing factors or consequences of AEs. The majority of the listed AEs appear to be new or different from those cited by other authors (e.g. Doran et al.6 and Lang et al.)13 Although beyond the scope of this review, a more in-depth analysis would be to have a panel of 'experts', including individuals receiving home care and families, to assess whether these reported AEs would/should be considered within current frameworks or be considered new and emerging specific to home care AEs.

Table 4 - Click to enlarge in new window Studies (

Risk of AEs

A subset of 24 studies (in 26 publications) reported risks related to AEs. The majority of these studies reported one specific AE, and one study reported on AEs generally. Studies focusing on the risk of specific AEs included: falls (six), medications (six), new visit to emergency room (three), pressure ulcers (three), infection (two), functional decline (one), injury (one) and malnourishment (one). Study designs included: descriptive (18), case control (three), cross-sectional (three) and observational cohort (one), with study samples ranging from 80 to 40279 participants. The specific AEs measured as outcomes were explicitly defined in only 14 of the 24 studies that assessed risk.


Although many risk factors were assessed and measured, only a few factors were measured more than once. The following lists only those risk factors that were mentioned twice or more: (i) inappropriate medication use - the number of medications (higher number of medications - higher risk) and age (Dalby et al.;32 Feldman et al.;33 Fialova et al.;34 Johnson et al.35); (ii) pressure ulcers - extent of immobility, extent of skin moisture or drainage, and the need for assistance with activities of daily living (Iizaka et al.;57 Bergquist and Frantz58); and (iii) new falls - medical instability, environmental hazards, age, male gender and history of previous falls (Leclerc et al.;76 Markle-Reid et al.;96 Byers et al.;66 Leclerc et al.;97 Scott et al.;67 Fletcher & Hirdes;98 Isberner et al.68).



In scoping the literature on safety with home care, an interesting aspect is the particular perspective of healthcare providers and patients. Although more studies (n=8) focused on healthcare provider perspectives, three studies (in four publications10,13,94,95) examined AEs from the perspective of patients and their families. An important issue emerging from these studies was the recognition that patient safety was inextricably linked to the safety of family members, caregivers and providers.10,13 Furthermore, family and friends as caregivers placed a level of complexity upon the relationship that confounded the ability to recognise and respond to AEs such as abuse or neglect.94 Eight studies9,36,37,38,39,59,69,99 addressed AEs from the perspective of healthcare providers. Of this set, the study sample of four studies was nurses,36,38,39,99 two studies addressed nursing assistants and nurse aids,37,59 one study69 targeted physiotherapists, and one other study9 addressed nurses and a range of healthcare professionals including decision makers, administrative executives, case managers and physicians. AEs examined in these studies included medication errors (four studies); general AEs (two studies); falls (one study) and pressure ulcers (one study). Studies that focused on medication errors raised several issues, notably the importance of provider knowledge to ensure safe delivery of care,37 helping patients to take their medications as intended38 and the failure to receive drugs, usually because of high costs which were seen as a problem in rural communities.39


Policies, practices and tools to reduce avoidable AEs

Eleven studies (two randomized controlled trials, eight descriptive, one observational) reported on a variety of strategies to address AEs in the home care setting. The countries represented (USA, six studies; Canada, three studies; Australia, two studies) have elements of both public and private healthcare systems and governmental agencies focused on safety and risk. Ten studies in the set focused on specific AEs and one study on AEs in general. AEs included: medication errors (five studies), falls (three studies), abuse (one study) and functional decline (one study). The total number of participants from all 11 studies was 3605 patients, and one study by Scharpf et al.,100 examined a total of 49 437 episodes of care (defined as first recorded Outcome and Assessment Information Set assessment during sample time frame for start of care or resumption of care). Seventy-three percent of the studies defined their focus AE. Strategies fell into two main groupings: management of risks (six studies) or the screening for risks (five studies) (Table 5).

Table 5 - Click to enlarge in new window Strategies to reduce avoidable AEs (
Table 5 - Click to enlarge in new window

Quality initiatives/projects literature

Nineteen papers were located from our search strategy that addressed quality initiatives that included evaluation components for individuals receiving home care services. This appears to be an important area of emerging evidence. These papers addressed the following issues (number of papers): falls (nine), infections (four), pressure ulcers (three), medication errors (two) and avoiding specimen transportation errors (one). With regard to safety and risk in home care, improvement initiatives often begin under a quality focus prior to formal research, and innovative solutions are described but not yet fully evaluated.



This study on patient safety in the home care environment revealed an emerging but limited evidence base. Significant effort was expended to develop and test the search methodology itself given the imprecise organisation of this field of research in the peer-review literature and the lack of consensus on what constitutes safety in home care. Following a systematic and rigorous process of testing multiple strategies, we compiled a comprehensive search document focused on the 'state of knowledge' related to the occurrence of AEs, related factors and strategies to reduce AEs, and outcomes using peer-review literature sources.


A predominant theme in this study has been the lack of conceptual clarity with the terms patient safety and AEs in the literature about the home care environment. As noted earlier, although the term 'harmful incident' is frequently used, the actual definition is the same. From the home care studies, we uncovered an anthology of 44 different AEs, of which about one-third fits into existing categorisations (e.g. Doran et al.;6 Lang et al.13). It begs the question whether these events should be considered AEs and/or whether current frameworks encompass events particular to care in the home. For example, there appears to be a tendency to consider changes in condition/disease, additional symptoms related to a condition and possibly even consequences of AEs (e.g. visit to emergency room, hospitalisations) as AEs. This phenomenon, as it relates to the home care setting, requires further study. The anthology of AEs compiled may provide the basis for a concept study as well as analyses in light of current quality and safety frameworks in practice and policy use in Canada and elsewhere.


Methodologically, the calculation of various AEs is challenged by the lack of conceptual clarity (e.g. for some authors, a new hospitalisation may be considered an AE, whereas for others, a care-related injury that leads to new hospitalisation is an AE; a patient fall without injury is an AE, whereas for others, only an injurious fall is an AE). Even with more observable events such as pressure ulcers, the issue of outcome is problematic (e.g. inclusion of Stage 1 (persistent redness) vs. Stage 2 and greater, vs All Stages as an AE). The concept issue should be considered of major importance in order to advance practice, policy and research in the area of home care patient safety. For those interested in advancements in home care safety, we may need to broaden typical approaches to the literature. Innovative strategies and tools surfaced in the in peer-review literature as quality initiatives with/without evaluation elements and provided an important area of emerging evidence. Good ideas operationalised in a specific context may offer a rich source for intervention development. To advance the field, it may be necessary to place more emphasis on this source.


Lastly, context is an important issue that surfaced in the research studies and deserves more attention in practice and policy circles. In one cross-cutting study in eight European countries,34 the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients were documented. Importantly, issues experienced at country, regional and local levels were highlighted with substantial differences in inappropriate medication use existing, possibly as a consequence of different regulatory measures, clinical practices or inequalities in socio-economic circumstances. Furthermore, financial resources and selected patient-related characteristics have to be considered as part of the process of prescribing. In the Canadian context, various provincial and territorial health jurisdictions each with its own regional differences render the implications from the European study relevant in Canada. The challenge is to determine what can be facilitated at a national level and what should be developed more locally. A scan of patient safety and professional websites reveals that the home care context is rarely addressed specifically in most policies and appears more of 'an afterthought'. There is some movement toward standardisation of safety policies in home care, but additional assistance in this area would be welcomed, for example, accreditation bodies and home care associations might consider standards for AE definition and reporting for the home care environment.


It was somewhat revealing that few studies focused on use of guidelines or other evidence-informed tools. There are many already developed guidelines for specific AEs (e.g. pressure ulcers, falls), but these may need adaptation to the home care environment. Although it is understandable that different jurisdictions and regions within a health system may need context-appropriate strategies and tools, it would be desirable to have a network approach to advance the knowledge. If similar regions or settings could collaborate on development and implementation of innovations, and funders could be encouraged to support evaluation, valuable field evidence about patient safety in home care would be produced.


Conclusion: where to go from here

Safety in home care is an important area of research given the current trend experienced by most health systems for care to be delivered outside of acute care settings. To further the field and provide useful evidence in practice and policy, several findings from this scoping review are pivotal.


Firstly, it is important for the home care safety field to consider approaches that amalgamate and evaluate existing research that encompasses all types of evidence. Further to issues of effectiveness, the nature of questions in home care safety includes acceptability and appropriateness, feasibility and meaning; each requires different and additional approaches to experimental designs. For instance, important questions about occurrence and risk factors may be answered by amalgamating evidence on observational designs and large cohort studies. Patient experience and response with AEs require exploratory, descriptive study designs that use qualitative and mixed methods. As well, mixed methods and qualitative research provide an important contribution for advancing conceptual clarity. As an emerging area of research, home care patient safety interventions and strategies may be first tested in quasi-experimental designs.


To synthesise evidence and conduct meta-analyses or meta-syntheses, several issues in development of search strategies and accessing relevant papers have been raised. Given the current structure of coding systems, this remains an important area for further study with the diverse patient populations and particular challenges presented in capturing studies about safety in the home care sector.


With primary research, self-reporting (by providers and patients) has been relied on in many studies. The lack of conceptual clarity with safety and AEs (generally or specific ones) raises the question of the reliability of this research. A return to a basic investigative level by the research community and those in the field to conduct concept analysis/clarification studies may be needed in order to advance the field.


A glaring limitation in the home care patient safety literature is the paucity of research on the occurrence of AEs and the lack of quality of the research that documents prevalence estimates and incidence rates. Sample frames vary widely with little use of tried and true observational study approaches (e.g. total population or random sampling with stratification) as does the time frame for tracking events. The quality of the source of information with validation of an AE was poorly reported or not done. Interventional research to evaluate risk reduction strategies is extremely limited at this time. It stands to reason that interventional research will advance only when the tracking and documentation of various AEs are improved.


Lastly, there are good examples in the literature of enquiries where high quality datasets are utilised with large samples. Such work will be further enhanced if it concurrently includes multi-methods and primary data collection alongside the large-scale database enquiries, for example, conducting survey or interviews with a random, or representatively selected, cohort drawn from the large datasets experiencing an AE at home to add additional and meaningful data.



*During this integrative study, the term 'adverse event' was changed to 'harmful incident' (World Health Organisation,3 (p.10); Canadian Patient Safety Institute,4 (p.8)). We have used 'adverse event' because it was the term used to search the literature to locate the current studies for this report. [Context Link]




1. Canadian Home Care Association. Portraits of Home Care in Canada. Ottawa, ON: The Canadian Home Care Association, 2008. [Context Link]


2. Auditor General of Ontario, Ontario Ministry of Health and Long-Term Care. 2010 Annual Report of the Office of the Auditor General of Ontario. Chapter 3, Section 3.04. Home Care Services. ON: The Queen's Printer, 2010. [Context Link]


3. World Health Organization WAfPS. More Than Words: Conceptual Framework for the International Classification for Patient Safety. Geneva: World Health Organization, 2009; Report No.: WHO/IER/PSP/2010.2. [Context Link]


4. Canadian Patient Safety Institute and Incident Analysis Collaborating Parties. Canaidan Incident Analysis Framework. Edmonton, AB: Canadian Patient Safety Institute, 2012. [Context Link]


5. Masotti P, McColl MA, Green M. Adverse events experienced by homecare patients: a scoping review of the literature. [Review] [132 refs]. Int J Qual Health Care 2010; 22: 115-125. [Context Link]


6. Doran DM, Hirdes J, Poss J et al. Identification of safety outcomes for Canadian home care clients: evidence from the resident assessment instrument - home care reporting system concerning emergency room visits. Healthc Q 2009; 12 Spec No Patient: 40-48. [Context Link]


7. Doran DM, Hirdes J, Blais R, Baker GR, Pickard J, Jantzi M. The nature of safety problems among Canadian homecare clients: evidence from the RAI-HC(c) reporting system. J Nurs Manag 2009; 17: 165-174. [Context Link]


8. Lang A, Edwards N. Safety in Home Care: Broadening the Patient Safety Agenda to Include Home Care Services. Edmonton, AB: Canadian Patient Safety Institute, 2006. [Context Link]


9. Masotti P, Green M, McColl MA. Adverse events in community care: implications for practice, policy and research. Healthc Q 2009; 12: 69-76. [Context Link]


10. Lang A, Macdonald M, Storch J et al. Home care safety perspectives from clients, family members, caregivers and paid providers. Healthc Q 2009; 12 Spec No Patient: 97-101. [Context Link]


11. Woodward C, Abelson J, Brown J, Hutchison B. Measuring Consistency of Personnel in Home Care: Current Challenges and Findings. Hamilton: McMaster University, 2002. [Context Link]


12. Henriksen K, Joseph A, Zayas-Caban T. The human factors of home health care: a conceptual model for examining safety and quality concerns. J Patient Saf 2009; 5: 229-236. [Context Link]


13. Lang A, Macdonald M, Stevenson L et al. State of the Knowledge Regarding Safety in Home Care in Canada: An Environmental Scan. Canadian Patient Safety Institute, 2009. [Context Link]


14. Grant MJ, Booth A. A Typology of Reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J 2009; 26: 91-108. [Context Link]


15. Arksey H, O'Malley L. Scoping reviews: towards a methodological framework. Int J Soc Res Methodol 2005; 8: 19-32. [Context Link]


16. The Cochrane Collaboration. The Cochrane review structure. The Cochrane Collaboration 2007. Accessed October 2007. Available from: [Context Link]


17. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers' Manual, 2008 edn. Adelaide, SA: The Joanna Briggs Institute, 2008. [Context Link]


18. Stone P. Popping the (PICO) question in research and evidence based practice. Appl Nurs Res 2002; 15: 197-198. [Context Link]


19. Tanon AA, Champagne F, Contandriopoulos AP, Pomey MP, Vadeboncoeur A, Nguyen H. Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL. Qual Saf Health Care 2010; 19: 452-461. [Context Link]


20. Westwood M, Rodgers M, Sowden A. Patient Safety: A Mapping of the Research Literature. York: NHS Centre for Reviews and Dissemination, 2002. [Context Link]


21. Sampson M, McGowan J, Lefebvre C, Moher D, Grimshaw J. PRESS: Peer Review of Electronic Search Strategies. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health (CADTH), 2008. [Context Link]


22. Ontario Ministry of Health and Long Term Care. Home, community and residential care services for seniors. Google 2013. Accessed 31 October 2012. Available from: [Context Link]


23. The Joanna Briggs Institute. The JBI approach to the systematic review of evidence. The Joanna Briggs Institute 2007. Accessed 21 October 2011. Available from: [Context Link]


24. Masotti P, Green M, Shortt SE, Hunter D, Szala-Meneok K. Adverse events in community care: developing a research agenda. Healthc Q 2007; 10: 59-65. [Context Link]


25. Institute of Medicine Committee on Quality of Healthcare in America. To Err Is Human: Building A Safer Healthcare System. Washington, DC: National Academy Press, 2000. [Context Link]


26. Woods DL, Guo G, Kim H, Phillips LR. We've got trouble: medications in assisted living. J Gerontol Nurs 2010; 36: 30-39. [Context Link]


27. Brown SL, Morrison AE, Parmentier CM, Woo EK, Vishnuvajjala RL. Infusion pump adverse events: experience from medical device reports. [Review] [13 refs]. J Intraven Nurs 1997; 20: 41-49. [Context Link]


28. Johnson M, Cusick A, Chang S. Home-screen: a short scale to measure fall risk in the home. Public Health Nurs 2001; 18: 169-177. [Context Link]


29. Paquay L, Wouters R, Defloor T, Buntinx F, Debaillie R, Geys L. Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice. J Clin Nurs 2008; 17: 627-636. [Context Link]


30. Schwien T, Gilbert J, Lang C. Pressure ulcer prevalence and the role of negative pressure wound therapy in home health quality outcomes. Ostomy Wound Manage 2005; 51: 47-60. [Context Link]


31. Meehan M, O'Hara L, Morrison YM. Report on the prevalence of skin ulcers in a home health agency population. Adv Wound Care 1999; 12: 459-467. [Context Link]


32. Dalby DM, Hirdes JP, Hogan DB et al. Potentially inappropriate management of depressive symptoms among Ontario home care clients. Int J Geriatr Psychiatry 2008; 23: 650-659. [Context Link]


33. Feldman PH, McDonald M, Rosati RJ et al. Exploring the utility of automated drug alerts in home healthcare. J Healthc Qual 2006; 28: 29-40. [Context Link]


34. Fialova D, Topinkova E, Gambassi G et al. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA 2005; 293: 1348-1358. [Context Link]


35. Johnson M, Griffiths R, Piper M, Langdon R. Risk factors for an untoward medication event among elders in community-based nursing caseloads in Australia. Public Health Nurs 2005; 22: 36-44. [Context Link]


36. Ellenbecker CH, Frazier SC, Verney S. Nurses' observations and experiences of problems and adverse effects of medication management in home care. Geriatr Nurs 2004; 25: 164-170. [Context Link]


37. Odegard S, Andersson DK. Knowledge of diabetes among personnel in home-based care: how does it relate to medical mishaps? J Nurs Manag 2001; 9: 107-114. [Context Link]


38. Stromme HK, Botten G. Drug-related problems among old people living at home, as perceived by a sample of Norwegian home care providers. J Soc Adm Pharm 1993; 10: 63-69. [Context Link]


39. Wolfgang AP, Jankel CA, McMillan JA. Drug information and educational needs. A survey of rural home health care nurses. Home Healthc Nurse 1993; 11: 20-23. [Context Link]


40. Seals AB, Duffy VG. Toward development of a computer-based methodology for evaluating and reducing medication administration errors. Ergonomics 2005; 48: 1151-1168.


41. Cannon KT, Choi MM, Zuniga MA. Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis. Am J Geriatr Pharmacother 2006; 4: 134-143.


42. Debre M, Clairicia M, Bonnaud F, Jubin O, Thiebaux-Boucard D. [Feasibility of administering Tegeline at home. Retrospective study of efficacy, safety and tolerance]. Presse Med 2004; 33: 682-688. (French).


43. Feldman PH, Bridges J, Peng T. Team structure and adverse events in home health care. Med Care 2007; 45: 553-561.


44. Flynn L. Extending work environment research into home health settings. West J Nurs Res 2007; 29: 200-212.


45. Gray SL, Mahoney JE, Blough DK. Adverse drug events in elderly patients receiving home health services following hospital discharge. Ann Pharmacother 1999; 33: 1147-1153.


46. Ibrahim IA, Kang E, Dansky KH. Polypharmacy and possible drug-drug interactions among diabetic patients receiving home health care services. Home Health Care Serv Q 2005; 24: 87-99.


47. Johnson KG. Adverse events among Winnipeg Home Care clients. Healthc Q 2006; 9 Spec No: 127-134.


48. Madigan EA. A description of adverse events in home healthcare. Home Healthc Nurse 2007; 25: 191-197.


49. Mager DD, Madigan EA. Medication use among older adults in a home care setting. Home Healthc Nurse 2010; 28: 14-21.


50. Meredith S, Feldman P, Frey D et al. Improving medication use in newly admitted home healthcare patients: a randomized controlled trial. J Am Geriatr Soc 2002; 50: 1484-1491.


51. Meredith S, Feldman PH, Frey D et al. Possible medication errors in home healthcare patients. J Am Geriatr Soc 2001; 49: 719-724.


52. Sears N. Harm from Home Care A Patient Safety Study Examining Adverse Events in Home Care. Toronto: University of Toronto (Canada), 2008.


53. Triller DM, Clause SL, Briceland LL, Hamilton RA. Resolution of drug-related problems in home care patients through a pharmacy referral service. Am J Health Syst Pharm 2003; 60: 905-910.


54. Triller DM, Clause SL, Hamilton RA. Risk of adverse drug events by patient destination after hospital discharge. Am J Health Syst Pharm 2005; 62: 1883-1889.


55. Ungvarski PJ, Rottner JE. Errors in prescribing HIV-1 protease inhibitors. J Assoc Nurses AIDS Care 1997; 8: 4-61.


56. Young HM, Gray SL, McCormick WC et al. Types, prevalence, and potential clinical significance of medication administration errors in assisted living. J Am Geriatr Soc 2008; 56: 1199-1205.


57. Iizaka S, Okuwa M, Sugama J, Sanada H. The impact of malnutrition and nutrition-related factors on the development and severity of pressure ulcers in older patients receiving home care. Clin Nutr 2010; 29: 47-53. [Context Link]


58. Bergquist S, Frantz R. Pressure ulcers in community-based older adults receiving home health care. Prevalence, incidence, and associated risk factors. Adv Wound Care 1999; 12: 339-351. [Context Link]


59. Goldsworthy RC. Home health aides' beliefs regarding pressure ulcer preventive care. Home Healthc Nurse 2008; 26: 113-120. [Context Link]


60. Bergquist S. The quality of pressure ulcer prediction and prevention in home health care. Appl Nurs Res 2005; 18: 148-154.


61. Chaves LM, Grypdonck MHF, Defloor T. Pressure ulcer prevention in homecare: do Dutch homecare agencies have an evidence-based pressure ulcer protocol? J Wound Ostomy Continence Nurs 2006; 33: 273-280.


62. Ferrell BA, Josephson K, Norvid P, Alcorn H. Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 2000; 48: 1042-1047.


63. Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living in community. Arch Gerontol Geriatr 2007; 44 (Suppl 1): 217-223.


64. Madigan EA, Tullai-McGuinness S. An examination of the most frequent adverse events in home care agencies. Home Healthc Nurse 2004; 22: 256-262.


65. Terry M, Halstead LS, O'Hare P et al. Feasibility study of home care wound management using telemedicine. Adv Skin Wound Care 2009; 22: 358-364.


66. Byers AL, Sheeran T, Mlodzianowski AE, Meyers BS, Nassisi P, Bruce ML. Depression and risk for adverse falls in older home health care patients. Res Gerontol Nurs 2008; 1: 245-251. [Context Link]


67. Scott VJ, Votova K, Gallagher E. Falls prevention training for community health workers: strategies and actions for independent living (SAIL). J Gerontol Nurs 2006; 32: 48-56. [Context Link]


68. Isberner F, Ritzel D, Sarvela P, Brown K, Hu P, Newbolds D. Falls of elderly rural home health clients. Home Health Care Serv Q 1998; 17: 41-51. [Context Link]


69. Peel C, Brown CJ, Lane A, Milliken E, Patel K. A survey of fall prevention knowledge and practice patterns in home health physical therapists. J Geriatr Phys Ther 2008; 31: 64-70. [Context Link]


70. Guillard G. [The faller at home]. Soins Gerontol 2005; 52: 21-23. (French).


71. Fletcher PC, Hirdes JP. Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing 2004; 33: 273-279.


72. Leclerc BS, Begin C, Cadieux E et al. A classification and regression tree for predicting recurrent falling among community-dwelling seniors using home-care services. Can J Public Health 2009; 100: 263-267.


73. Lewis CL, Moutoux M, Slaughter M, Bailey SP. Characteristics of individuals who fell while receiving home health services. Phys Ther 2004; 84: 23-32.


74. Markle-Reid M, Browne G, Gafni A et al. A cross-sectional study of the prevalence, correlates, and costs of falls in older home care clients 'at risk' for falling. Can J Aging 2010; 29: 119-137.


75. Smith J, Lewin G. Home care clients' participation in fall prevention activities. Australas J Ageing 2008; 27: 38-42.


76. Leclerc BS, Begin C, Cadieux E et al. Relationship between home hazards and falling among community-dwelling seniors using home-care services. Rev Epidemiol Sante Publique 2010; 58: 1-11. [Context Link]


77. Matthias RE, Benjamin AE. Abuse and neglect of clients in agency-based and consumer-directed home care. Health Soc Work 2003; 28: 174-184.


78. Stolee P, Poss J, Cook RJ, Byrne K, Hirdes JP. Risk factors for hip fracture in older home care clients. J Gerontol A Biol Sci Med Sci 2009; 64: 403-410.


79. Rosenheimer L, Embry FC, Sanford J, Silver SR. Infection surveillance in home care: device-related incidence rates. Am J Infect Control 1998; 26: 359-363.


80. Marrie TJ, Huang JQ. Community-acquired pneumonia in patients receiving home care. J Am Geriatr Soc 2005; 53: 5-839.


81. Weber DJ, Brown V, Huslage K, Sickbert-Bennett E, Rutala WA. Device-related infections in home health care and hospice: infection rates, 1998-2008. Infect Control Hosp Epidemiol 2009; 30: 10-1024.


82. Ireton-Jones C, DeLegge M. Home parenteral nutrition registry: a five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support. Nutrition 2005; 21: 2-160.


83. Shah SS, Manning ML, Leahy E, Magnusson M, Rheingold SR, Bell LM. Central venous catheter-associated bloodstream infections in pediatric oncology home care. Infect Control Hosp Epidemiol 2002; 23: 99-101.


84. Do AN, Ray BJ, Banerjee SN et al. Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting. J Infect Dis 1999; 179: 442-448.


85. Gorski LA. Central venous access device outcomes in a homecare agency: a 7-year study. J Infus Nurs 2004; 27: 104-111.


86. Visvanathan R, Macintosh C, Callary M, Penhall R, Horowitz M, Chapman I. The nutritional status of 250 older Australian recipients of domiciliary care services and its association with outcomes at 12 months. J Am Geriatr Soc 2003; 51: 1007-1011.


87. McDonald MV, King LJ, Moodie M, Feldman PH. Exploring diabetic care deficiencies and adverse events in home healthcare. J Healthc Qual 2008; 30: 5-12.


88. Hayasaka S, Okayama M, Ishikawa S, Nakamura Y, Kajii E. Accidents associated with bathing in home care services for the aged in Japan. J Epidemiol 2001; 11: 139-142.


89. Taft SH, Pierce CA, Gallo CL. From hospital to home and back again: a study in hospital admissions and deaths for home care patients. Home Health Care Manage Pract 2005; 17: 467-480.


90. Paddock K, Hirdes JP. Acute health care service use among elderly home care clients. Home Health Care Serv Q 2003; 22: 75-85.


91. Dahlgren AF. Adverse drug reactions in home care patients receiving nafcillin or oxacillin. Am J Health Syst Pharm 1997; 54: 1176-1179.


92. Madigan EA, Schott D, Matthews CR. Rehospitalization among home healthcare patients: results of a prospective study. Home Healthc Nurse 2001; 19: 298-305.


93. Rosati RJ, Huang L, Navaie-Waliser M, Feldman PH. Risk factors for repeated hospitalizations among home healthcare recipients. J Healthc Qual 2003; 25: 4-10.


94. Saxton M, Curry MA, Powers LE, Maley S, Eckels K, Gross J. 'Bring my scooter so I can leave you': a study of disabled women handling abuse by personal assistance providers. Violence Against Women 2001; 7: 393-417. [Context Link]


95. Saxton M, McNeff E, Powers L, Curry MA, Limont M, Benson J. We're all little John Waynes: a study of disabled men's experience of abuse by personal assistants. J Rehabil 2006; 72: 3-13. [Context Link]


96. Markle-Reid M, Browne G, Gafni A et al. The effects and costs of a multifactorial and interdisciplinary team approach to falls prevention for older home care clients 'at risk' for falling: a randomized controlled trial. Can J Aging 2010; 29: 139-161. [Context Link]


97. Leclerc BS, Begin C, Cadieux E et al. Risk factors for falling among community-dwelling seniors using home-care services: an extended hazards model with time-dependent covariates and multiple events. Chronic Dis Can 2008; 28: 4-120. [Context Link]


98. Fletcher PC, Hirdes JP. Risk factors for falling among community-based seniors using home care services. J Gerontol A Biol Sci Med Sci 2002; 57: M504-M510. [Context Link]


99. Salem SA. Home Health Nurses' Care Errors. Lexington, KY: University of Kentucky, 2006. [Context Link]


100. Scharpf TP, Colabianchi N, Madigan EA et al. Functional status decline as a measure of adverse events in home health care: an observational study. BMC Health Serv Res 2006; 6: 162. [Context Link]


Key words:: adverse event; harmful incident; home healthcare; patient safety; synthesis.