Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification

BACKGROUND: There is a paucity of patient safety information from the community sector related to the medically fragile population requiring home mechanical ventilation (HMV). To improve safety, the risks HMV patients encounter must first be understood. OBJECTIVES: To describe patient safety incidents within the HMV population and discuss opportunities for preventing harm. METHODS: A retrospective observational review of on-call logs from the Ontario Ventilator Equipment Pool (VEP) was conducted. Classification of 248 on-call logs from April 1, 2011 to March 21, 2012 was completed using the standardized tool of the World Health Organization’s (WHO) Patient Safety Taxonomy – International Classification System to quantitatively describe the types of incidents arising. Analysis of data classification was completed using descriptive and nonparametric statistics. RESULTS: Patient incidents were positive in 188 on-call logs; emerging from these were 227 incident types. Patient incident types included medical device issues (99 device failures, 41 user errors, 12 equipment availability), documentation (20 unavailable labels/prescriptions, four unclear information), clinical processes (16 inadequate treatment or general care) and clinical administration (10 inadequate handover or transfer of care). Patient incidents were associated with mild harm in 87 cases. CONCLUSIONS: The on-call logs were a good source of quality improvement data to understand harm and patient safety issues emerging in the HMV population. However, establishing a formal incident review and reporting system is required to provide a more comprehensive understanding.