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  1. Castro, Gerard M. PhD, MPH, PMP

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Home care organizations face unique circumstances that make providing high-quality, safe care challenging for visiting clinicians, patients, and their families. Circumstances such as patients being sent home with complicated conditions, unanticipated burden on family members to care for their loved ones, managing supplies and confusing medical technology, home environments that can pose fall risks for patients, and sometimes patients with a limited network of support or access to resources are common challenges (Institute for Healthcare Improvement, 2018).


A Sentinel Event is a patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm with intervention required to sustain life. Such events are called "sentinel" because they signal the need for immediate investigation and response. The Joint Commission accredited organizations are strongly encouraged, but not required, to report Sentinel Events to The Joint Commission as an opportunity to learn from these events. From 2008 to 2018, over 9,000 Sentinel Events have been reported. Unfortunately, only a small proportion of these events were reported from organizations in the home care program (Figure 1), and it is difficult to learn when all events are not reported. However, when reviewed in aggregate most Sentinel Events reported from home care organizations were fires associated with smoking while oxygen was in use and falls that resulted in severe harm to the patient or death (Figure 2).

Figure 1 - Click to enlarge in new windowFigure 1. Sentinel Event Settings, 2008 to 2018
Figure 2 - Click to enlarge in new windowFigure 2. Home Care-Related Sentinel Events, 2008 to 2018

Visiting clinicians educate patients on the danger of fire associated with oxygen use and encourage patients to quit smoking, helping prevent fires related to smoking while oxygen in use. These types of events are rare but when they occur, they are catastrophic. The fires usually lead to death or severe injuries to patients, and sometimes loss of home and death of family members.


Patient falls are a more common problem. Many of the reported falls occurred while the patient was ambulating or attempting to get out of bed. Visiting clinicians help reduce the risk of falls by knowing their patients' condition, the medications they are taking, their home environment, and managing the associated fall risks.


Successfully managing the multitude of challenges requires a systems-based approach to safety. The Patient Safety System Chapter in The Joint Commission Home Care Accreditation Manual (2018) describes a proactive approach to designing an integrated system that protects patients from harm and improves quality and patient safety. The chapter lists the standards and requirements that support a patient safety system that leaders can reference while striving for zero harm (2019). Essential components to a successful patient safety system and striving for zero harm are:


* Ensuring that leadership is committed to a goal of zero harm


* Developing and adopting a safety culture


* Incorporating highly effective process improvement tools and methodologies (Robust Process Improvement) in your work


* Demonstrating how everyone is accountable for safety and quality



Sharing and reporting can be difficult if there is fear of retribution, the belief that nothing will be done, or even not knowing what unsafe conditions or events to report. Reporting Sentinel Events to The Joint Commission not only provides the basis for greater learning, but also the opportunity to work with patient safety specialists on analysis of the event and learning how to reduce the risk of future events.


Zero harm does not mean zero mistakes, but rather accepting that as humans we will make mistakes, and it is up to us to learn from our mistakes. An effective patient safety system cultivates a culture that encourages reporting of hazardous or unsafe conditions and patient safety events in order to learn and improve. As leaders, we accept that we are all human and make mistakes, but we can create the conditions for people to be willing to learn and to design safe systems and processes to prevent future mistakes.




Institute for Healthcare Improvement. (2018). No place like home: Advancing the safety of care in the home. Retrieved from http://www.ihi.org/resources/Pages/Publications/No-Place-Like-Home-Advancing-Saf[Context Link]


The Joint Commission. (2018). Home Care Accreditation Manual. Oakbrook Terrace, Illinois: Author. [Context Link]


The Joint Commission. (2019). Leading the way to zero. Retrieved from https://www.jointcommission.org/leadingthewaytozero.aspx