Samenvatting

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 systenaticaly.
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.