There's no place like home: research, practice and policy perspectives regarding safety in homecare.

Since 1997, the number of homecare clients in Canada has increased by 51% [1]. As suggested by Masotti et al. in this issue of the International Journal of Quality in Health Care, this dramatic increase in the amount, acuity and complexity of healthcare being provided in peoples' homes has grown at a much faster pace than has the body of research on patient safety, which to date has focused predominantly on institutional settings [2]. Nonetheless, emergent shifts in thinking evident in recent patient safety literature are also pertinent to homecare. These include the views that patient safety is mostly perceived as a systems' failure rather than a human failure [3– 4], that organizational culture and workplace factors influence patient safety [5], that multiple change processes are necessary to create safe environments [6] and that patients play a key role in their care and thus must be included in the patient safety dialogue [7]. In this editorial, I describe some of the recent Canadian initiatives and reflect on existing gaps in knowledge and the complexity of advancing our understanding of the issues and challenges around homecare safety. Homecare safety is about mitigating the risks in diverse environments that are uncontrolled and unregulated [8]. Risks exist in all health-care settings; however, private homes lack the uniformity that exists in institutional/hospital environments. Homes are not designed for providing or receiving health-care services rather they are designed for living. Homecare is superimposed on the 'everyday' circumstances of peoples' lives. Consequently, in contrast to institutions of care, there are no national standards in place regarding the physical environment in which homecare services are provided. Indeed, the notion of standards for homecare safety needs to undergo a re-visioning process in light of consistent and persistent reports that the context of homecare is highly variable [9]. Within the past 5 years, the Canadian Patient Safety Institute (CPSI) in collaboration with VON Canada (a national not-for-profit home and community care organization) have recognized the urgent need and spearheaded a number of initiatives to examine homecare safety. A comprehensive report, entitled 'Safety in Homecare: Broadening the Patient Safety Agenda to Include Homecare Services' [8], identified that addressing homecare safety presents unique challenges and requires a major reexamination of underlying assumptions and guiding frameworks that have been used to examine patient safety in the institutional environment. Some of the central themes identified in this foundational report included: the inextricably linked …