Problem and Evidence Assignment

Clinical Problem Description 

Incidents and adverse events resulting in patient injuries in healthcare facilities and home care settings are significant public health problems worldwide (Ree & Wiig, 2019). Four out of 10 patients who receive care in primary and ambulatory care settings, including home care, suffer injuries (World Health Organization [WHO], 2020). Adverse events regularly occur within the healthcare system, where at least 1 in 10 patients are affected in America (Skelly et al., 2021). In the United States, more than 250,000 patients who receive medical care experience an adverse event annually. Another 100,000 patients die from adverse events (Skelly et al., 2021). Millions of Americans use home health services in the United States and experience more incidents than their counterparts in nursing homes or adult daycare settings (Centers for Disease Control and Prevention [CDC], 2019). The most commonly reported incidents in the home care settings are falls (18.8%), infections (21.8%), pressure ulcers (17.0%), and psychosocial harm (4.4%) (Schildmeijer et al., 2018). These incidents are associated with emergency department visits (15.3%) and overnight hospital stays (15.7%) (CDC], 2019). 

Most incidents, including hospital-acquired infections, falls, medication errors, faulty or misused equipment, incompetent staff performance, and even patient deaths, are preventable (WHO, 2020). Incident reporting (IR) is among the ideal measures to improve patients’ safety since it facilitates incident monitoring and possibly prevents future occurrences through implementing evidence-based countermeasures (Hamed & Konstantinidis, 2021). Reporting further presents an opportunity to investigate and gather helpful information. As a result, potential risks and issues related to system deficiencies are identified (Yamamoto-Takiguchi et al., 2021). Nevertheless, incidents or adverse events within a home care setting are often under-reported (Ree & Wiig, 2019). Low or a lack of incident reporting by caregivers exposes patients to additional risks. Lack of incident reporting is primarily linked to fear of retaliation, the amount of time required to complete a report, absence of supportive culture, failure by the agency to implement measures, and lack of manager support (Duffey et al., 2019).

The issue of incident or adverse event under-reporting at the practice is evident Often, caregivers at the homecare fail to report incidents as required by the facility’s policy. There are multiple incidences of non-reporting of adverse events and incidents. Injuries sustained by the clients due to under-reporting result in the emergency department or urgent care visits or hospitalizations which often lead to the transfer of patients to a long-term care facility based on the agency’s discharge records. Lack of reporting causes non-compliance issues with the agency’s Medicaid incident reporting requirements. For example, failure to report an incident resulted in the homecare agency receiving a state-led investigation visit. Potential lawsuit by clients and family members due to underreporting may result in considerable financial implications, and agency’s reputation might be adversely affected.  

  Despite the agency having a safety culture, it is challenging to change staff perceptions to increase incident reporting. Staff attribute under-reporting to not knowing that the incident was reportable, fear of being blamed or looked upon as a bad employee, unwillingness to fill out the incident form, and client request not to report the incident to the agency for fear of being transferred from the facility. In addition, when staff caused the incident, they did not want the agency to know. This implies the need to implement measures to address the issue at the practice site. According to Duffey et al. (2019), homecare caregivers can significantly impact incident reporting by documenting all actual and near-miss incidences, improving patient safety, and decreasing incidence-related costs. Thus, addressing the lack of incident reporting by caregivers in the homecare setting may improve the overall patient experience, reduce the number of incidents occurring in the home, and ultimately lower healthcare costs by decreasing incident-related costs. 

Research Evidence Description 

Past studies show a positive relationship between caregiver education and knowledge and reported incidences in care facilities (Müller et al., 2019; Rummel et al. (2021). A quasi-experimental project by Müller et al. (2019) aimed to enhance the use of critical incident reporting systems. The intervention included educating and training practice staff to introduce them to a newly integrated web-based incident reporting system. Practice team members were required to report incidents anonymously. A total of 17 critical incidents were reported after 20 months of implementing this quality improvement project. Upon completion of the project, participants scored higher in terms of patient safety. 

In another study, Rummel et al. (2021) carried out a six-weeks pre/post-project in a long-term facility. The intervention involved educating and coaching certified nurse assistants to communicate early skin changes to nurses. Thirty-one residents with an average age of 87 were recruited for the project and followed for pressure injury incidence over six weeks. A communication guideline about skin, cleanliness, activity, and nutrition was created for certified nurse assistants. Additionally, pre-and post-intervention outcomes of pressure injuries knowledge and skills were measured among 24 certified nurse assistants over six weeks. The results indicated statistically significant improvement in comfort in identifying and reporting skin changes (Z = –1.933, p = 0.053. This was evidenced by a reduction in pressure injuries from 9,6% to 0% by the end of week 3.    

A cluster-randomized trial by verbakel et al. (2015) examined the impact of patient safety culture interventions on incident reporting as a representation of safety culture. The study was conducted within 30 general practices. Participants included general practitioners, assistants, nurses, and others. A total of 10 practices were randomized into the controlled group, 10 in the intervention I group, and 10 in intervention group II. The sample was as follows; controlled group (n=67), intervention 1 group (n=87), and intervention 11 group (n=81). Intervention I and II groups intervention groups completed a patient safety culture survey and attended a 3.5- hour educational workshop about patient safety. Approximately 66 staff in the intervention II group attended the workshop. Findings revealed that both intervention groups had an increased reporting rate than the control group (82 and 224 in interventions I and II, respectively). The group receiving the survey and attending the workshop (intervention II) increased the number of incidents reported by 154 (from 70 to 224), and the control group decreased from 18 to 4. 

Like verbakel et al. (2015), Teresi et al. (2013) implemented a randomized cluster trial. The study was conducted within a homecare setting to examine the impact of education on certified nursing assistants’ knowledge, identification, and incident reporting (resident-to-resident elder mistreatment [R-REM]) pots-training. The educational sessions covered recognition and risk factors, management, and implementation of guidelines. A total of 1405 residents (685 in control and 720 in the experimental group) from 47 nursing home units (23 experimental and 24 control) in five nursing homes took part in this research. The results indicated statistically significant improvement in nursing assistants’ knowledge for modules 1 and 2 (p < 0.001 and p < 0.001, respectively).

In summary, the available evidence supports the implementation of an educational intervention to increase staff knowledge and incident reporting. Most of the evidence was obtained from settings other than home care. However, an intervention to improve incident reporting by certified nursing assistants in long-term care facilities may be successfully replicated in home settings among caregivers.


Centers for Disease Control and Prevention (2019). Long-term care providers and services users in the United States, 2015–2016.

Duffey, P., Oliver, J. S., & Newcomb, P. (2019). Evaluating the use of high-reliability principles to increase error event reporting.  Journal of Nursing Administration49(6), 310-314.

Hamed, M. M., & Konstantinidis, S. (2021). Barriers to incident reporting among nurses: A qualitative systematic review. Western Journal of Nursing Research, 1-18.

Müller, B. S., Beyer, M., Blazejewski, T., Gruber, D., Müller, H., & Gerlach, F. M. (2019). Improving critical incident reporting in primary care through education and involvement. BMJ Open Quality8(3), 1-5.

Ree, E., & Wiig, S. (2019). Employees’ perceptions of patient safety culture in Norwegian nursing homes and home care services. BMC Health Services Research19(1), 1-7.

Rummel, E., Evans, E. M., & O’Neal, P. V. (2021). Educating certified nursing assistants to communicate skin changes to reduce pressure injuries. Journal of Gerontological Nursing47(8), 21-28.

Schildmeijer, K. G., Unbeck, M., Ekstedt, M., Lindblad, M., & Nilsson, L. (2018). Adverse events in patients in home healthcare: A retrospective record review using trigger tool methodology. BMJ Open8(1), 1-11.

Skelly, C. L., Cassagnol, M., & Munakomi, S. (2021). Adverse events. In StatPearls [Internet]. StatPearls Publishing.

Teresi, J. A., Ramirez, M., Ellis, J., Silver, S., Boratgis, G., Kong, J., Eimicke, J. P., Pillemer, K., & Lachs, M. S. (2013). A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial. International Journal of Nursing Studies50(5), 644-656.

Verbakel NJ, Langelaan M, Verheij TJ, Wagner C, & Zwart DL. (2015). Effects of patient safety culture interventions on incident reporting in general practice: A cluster randomised trial. British Journal of General Practice65(634), e319–e329.

World Health Organization. (2020). Patient safety incident reporting and learning systems: technical report and guidance.

Yamamoto-Takiguchi, N., Naruse, T., Fujisaki-Sueda-Sakai, M., & Yamamoto-Mitani, N. (2021). Characteristics of patient safety incident occurrences reported by Japanese Homecare nurses: A prospective observational study. Nursing Reports11(4), 997-1005.