Table 1.

Summary of Common Patient Safety Harms and Contributing Factors

(1) Most common categories of patient safety incidents leading to harm

A. Injuries from falls

B. Inadequate control of symptoms, particularly pain

(2) Most commonly described hazards and contributing factors for patient safety incidents

• Frail or debilitated patients living alone, or being left alone by caregivers (the most commonly described contributing factor in phase 1 interviews)

• Caregiver's physical and/or cognitive limitations

• Patients' physical and/or cognitive limitations

• Patient or caregiver difficulty in understanding care instructions

• Family or caregiver attitudes or disagreements with hospice care plans

• Nonadherence to instructions given by the hospice team

• Families not accepting short prognosis and “forcing” activity by a dying patient

• Family members overwhelmed with their role as caregivers

• Poor or physically hazardous living conditions

• Rapid increases in patient weakness/debility

• Patient/caregiver fears regarding medication, particularly opioids

• Patient/caregiver poor understanding of dosing instructions

• Dosing errors by patients/caregivers

• Medication diversion by family members or caregivers

• Delays in prescribing/delivering medications to the patient's home

• Physician reluctance or delays in prescribing medications