Examining "operational failures" to reduce home care errors

The majority of health care errors that impact patient safety can be linked not to caregivers' lack of skills or knowledge, but to faulty work design (Perrow 1984; Reason 1990). Yet little is known about operational failures in home health care that lead to adverse events. This article summarizes the findings of a recent case study (Tucker 2004) that identifies 23 operational failures that took place during seven home care visits over the course of one day. The majority of these failures were linked to either the patient/family or the home health agency servicing the family rather than to the individual nurse treating the patient. Findings suggest that to understand and reduce errors in home health care, further examination of the structure of the work environment is necessary to create an atmosphere that can promote better patient care.