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The Joint Commission on Accreditation of Healthcare Organizations reports that there have been 11 sentinel events related to home health care patients and suggests that risk managers overseeing home health care should study the incidents for ways to alleviate the risk of fire.
The 11 sentinel events reported since April 1997 involved home health patients who were injured or killed as a result of a fire in the home. Each of the patients was receiving supplemental oxygen service, and all were over the age of 65. The Joint Commission’s investigations revealed these risk factors for home-care related fires: living alone, lack of smoke detectors or presence of nonfunctional smoke detectors, cognitive impairment, an identified history of smoking while oxygen is running, and flammable clothing.
Seven of the patients died, and four others suffered loss of function or permanent disfigurement. The investigations revealed that cigarette smoking was a contributing factor in each case.
The root-cause analyses by the home care providers identified root causes that contributed to the fires in the home. More than one-third of the cases involved inconsistent identification of smokers and missed reassessment visits. For 18% of the cases, the Joint Commission says the reporting organizations determined that "they lacked a sufficient process for considering the termination of services to patients who persistently refuse to comply with prescribed precautions."
In assessing caregivers, "nearly three-quarters of the cases identified that caregivers needed to increase their emphasis on home safety, while 45% of cases identified incomplete orientation processes for new staff. More than one-third of the cases found that caregiver training was not coordinated among the health care providers."
With regard to the environment of care, the root-cause analyses revealed that in 55% of the cases, there was no process in place for testing the smoke alarms; and in 36% of the cases, no home safety assessment process was in place. In 18% of the cases, there was no identified plan or testing for evacuation in the event of a fire.
The Joint Commission reports that the home care organizations identified a number of communication factors, including failure to notify the primary care physician when a patient was noncompliant (73%); weak communication between home care providers, for example, between home health nursing service and oxygen equipment providers (55%); and delayed reporting of hazardous conditions to the home care management team. Nearly half of the providers, 45%, recommended improved staff training and orientation, especially with regard to identifying smokers and managing their care. Other recommendations included appointing a fire safety specialist or trainer and involving the fire department in employee and patient education activities.
In recommendations regarding process design, 64% recommended procedures for notifying the physician when a patient is noncompliant, and 55% recommended procedures to improve communication between health care providers. The home health organizations also recommended providing patients with smoking cessation information and assistance and involving the home care organization’s ethics committee in reaching a decision to terminate home care services to noncompliant patients.
Noting that the presence of a smoke detector is crucial in saving lives once a fire breaks out, 55% of the organizations recommended procedures for obtaining, testing, and locating smoke detectors in the home. Overall home safety assessments were recommended by 36%.