Penny Hollander Feldman, Ph.D., Co-Principal Investigator
Christopher Murtaugh, Ph.D., Co-Investigator
Robert Rosati, Ph.D., Co-Investigator
Margaret McDonald, M.S.W.,, Research Associate
Lori King, Research Analyst
Center for Home Care Policy and Research, Visiting Nurse Service of New York

Christine Kovner, Ph.D., R.N., F.A.A.N., Principal Investigator
Judith D. Goldberg, Sc.D., Co-Investigator
Barbara Krainovich-Miller, Ed.D., R.N., C.S., Visiting Professor
Joyce Menezes, Research Assistant
New York University

Background: Home care operates at the intersection of a diverse set of factors: It often involves managing complex care for patients with multiple health conditions. Care is highly decentralized, with as many sites of care as there are patients, and informal caregivers play a prominent role. In addition, new payment systems and regulatory requirements have both restricted home care and placed a greater emphasis on quality.

As an aging population creates increases in demand for home care services, more needs to be done to understand and prevent medical errors in this care setting.

Purpose: To advance the understanding of and teaching about medical errors in home health care and to develop ways to learn from such errors and thereby reduce them.

Study Design: Research, Education, and Assessing Care for Homecare Safety (REACHomeS) was a joint project of VNSNY's Center for Home Care Policy and Research and new York University's (NYU) Division of Nursing at the Steinhardt School of Education. The aim of this initiative was to improve upon the intellectual resources and disciplinary skills, measurement tools and organizational techniques for understanding medical errors in home health care. These aims were to be met by (1) developing a multi-disciplinary team to conduct research on patient safety, (2) strengthening ties between NYU's Division of Nursing (DON) and VNSNY, (3) developing educational programs on the importance of patient safety and evidence-based approaches to improving it, and (4) conducting research pilot studies.

Finding: Selected Initiative Activities

Educational Program: The NYU Division of Nursing in collaboration with NYU's Wagner School and VNSNY developed a Leadership Institute for mid level nurse managers at VNSNY. The focus of the Leadership Institute was on general management training. Managers attended the Institute in groups of 20. Dr. Kovner coducted several three-hour educational sessions for each group and addressed patient safety issues.

Software Development:Joyce Menezes developed a CD-ROM entitled Medication Management in the Home. This product allows nurses to view VNSNY's medication policies and to self-assess their knowledge regarding these policies. This CD-ROM will be showcased on September 26-28, 2004 at the 3rd Annual AHRQ Patient Safety Conference in Arlington, Virginia.

Pilot Study:This pilot examined the use of an automated drug utilization review system in a large home health agency. Data was analyzed on 300 patients with chronic conditions. It was found that the system generated many alerts that were potentially distracting nurses from more serious potential problems. However, expert reviewers judged that over 40% of high-risk diabetic patients and over 50% of high-risk hypertension patients did generate alerts that required nurse follow-up although a sizable proportion did not receive it. Less "noisy" alert systems may be needed.

Publications:

Feldman, P., McDonald, M., Rosati, R., Murtaugh, C., Kovner, C.T., Goldberg, J.D. & King, L.
Exploring the potential utility of automated drug alerts in home health care.
Journal of Healthcare Quality 28(1):29-40.

Kovner, C., Menezes, J., Goldberg, J.D.
Examining Nurses' Decision Process for Medication Management in Home Care.
Journal on Quality and Patient Safety 31(7):379-385.

Sponsor: Agency for Healthcare Research and Quality (AHRQ)