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Reporting incidents involving the use of advanced medical technologies by nurses in home care: a cross-sectional survey and an analysis of registration data
  1. Ingrid ten Haken1,
  2. Somaya Ben Allouch2,
  3. Wim H van Harten3,4
  1. 1Research Group Technology, Health & Care, Saxion University of Applied Sciences, Enschede, The Netherlands
  2. 2Research Group Digital Life, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
  3. 3Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
  4. 4CEO, Rijnstate General Hospital, Arnhem, The Netherlands
  1. Correspondence to Ingrid ten Haken, Research Group Technology, Health & Care, Saxion University of Applied Sciences - AMM, P.O. Box 70.000, Enschede 7500 KB, The Netherlands; i.tenhaken{at}saxion.nl

Abstract

Background Advanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systematically.

Objectives To identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents.

Methods A cross-sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used.

Results We identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation’s protocol.

Conclusions Most incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.

  • incident reporting
  • nurses
  • patient safety
  • healthcare quality improvement
  • risk management
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Footnotes

  • Contributors ItH was involved in the conception and design of the study, acquisition, collection of data, analysis and interpretation of data and drafting the article. SBA and WvH have made substantial contributions to the conception and design of the study, the analysis and interpretation of data and revising the article critically for important intellectual content. All authors have approved the final article, this submission and its publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer This article describes original work, has not been published previously and is not under consideration by any other journal. All authors meet the criteria for authorship and all those entitled to authorship are listed as authors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. The data that support the findings of this study are available from the corresponding author ItH, on reasonable request.

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