title: Patient safety incidents in hospice care: observations from interdisciplinary case conferences.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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?
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 1 Curtis W. and Ann H. Long Department of Family and Community Medicine, School of Medicine, University of Missouri , Columbia, Missouri.
authors.forename: Debra Parker
authors.initials: DP
authors.lastname: Oliver
authors.forename: George
authors.initials: G
authors.lastname: Demiris
authors.forename: Elaine
authors.initials: E
authors.lastname: Wittenberg-Lyles
authors.forename: Ashley
authors.initials: A
authors.lastname: Gage
authors.forename: Mariah L
authors.initials: ML
authors.lastname: Dewsnap-Dreisinger
authors.forename: Jamie
authors.initials: J
authors.lastname: Luetkemeyer
mesh_terms: D006126:Group Processes; D017051:Hospice Care; D006801:Humans; D033183:Interdisciplinary Communication; D015146:Midwestern United States; D064406:Patient Harm / Q000517:prevention & control; D061214:Patient Safety; D012189:Retrospective Studies; D019035:Rural Health Services; D017751:Safety Management / Q000458:organization & administration*; D014741:Video Recording