Recommended Citation
Grannan H, Riutta S, Sharma K. Balancing Safety and Quality with End-of-Life Realities: A Single Inpatient Hospice Facility Review. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Background/Significance:
Patient safety in hospice care requires balancing traditional safety metrics with individualized, comfort-focused goals at the end of life. Inpatient hospice units manage complex symptoms, high-risk medications, and dynamic family preferences, yet limited literature characterizing safety events in this setting. Despite routine event reporting, no comprehensive evaluation of safety incidents has been conducted at Zilber Family Hospice (ZFH).
Purpose:
The purpose of this project was to characterize and analyze patient safety incidents at ZFH to identify patterns, clarify event categorization, and inform hospice-specific safety practices and staff education that support comfort and harm reduction.
Methods:
Safety incidents at ZFH reported on the Origami platform in 2024 were reviewed. Extracted data included patient MRN, date, event category, and description; data were supplemented with review of electronic medical records and unit logs. Events were categorized by Origami classification, and thematic analysis refined subcategories for greater specificity. Aggregate 2024 hospice-wide data (n=975 patients) was used for comparison. Descriptive statistics and Chi-squared tests are used as appropriate.
Results:
Of 102 reported events, exclusions for prior-year events, duplicates, and non-admitted patients yielded 92 unique events. Eighty-three (90%) were patient-related, and 72 included a patient with MRN representing 64 patients. Median patient age was lower than the whole-hospice median (69 years (IQR 60–79) vs. 76 years). Racial/ethnic distribution differed significantly (p<0.0001). Thirty-nine percent of safety events occurred on the day of admission and 83% within 7 days of admission. The most common event categories were Care Related (35%) and Medication Event (24%). Review of Care Related events showed 38% were miscategorized; the remaining 62% were subcategorized into groups such as “unsafe transfer” and “missing order” for greater detail.
Conclusion:
Safety events occurred predominantly early in admission and were most often care-related or medication-related. The patients experiencing events differed from the broader hospice population, including a significantly different racial and ethnic distribution. Misclassification within the reporting system highlights the need for refined hospice-specific categories. These findings support targeted education and focused attention on admission of workflows to better align safety practices with equitable, patient-centered end-of-life care.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
wf_yes
Document Type
Poster
Open Access
Available to all.
Balancing Safety and Quality with End-of-Life Realities: A Single Inpatient Hospice Facility Review
Background/Significance:
Patient safety in hospice care requires balancing traditional safety metrics with individualized, comfort-focused goals at the end of life. Inpatient hospice units manage complex symptoms, high-risk medications, and dynamic family preferences, yet limited literature characterizing safety events in this setting. Despite routine event reporting, no comprehensive evaluation of safety incidents has been conducted at Zilber Family Hospice (ZFH).
Purpose:
The purpose of this project was to characterize and analyze patient safety incidents at ZFH to identify patterns, clarify event categorization, and inform hospice-specific safety practices and staff education that support comfort and harm reduction.
Methods:
Safety incidents at ZFH reported on the Origami platform in 2024 were reviewed. Extracted data included patient MRN, date, event category, and description; data were supplemented with review of electronic medical records and unit logs. Events were categorized by Origami classification, and thematic analysis refined subcategories for greater specificity. Aggregate 2024 hospice-wide data (n=975 patients) was used for comparison. Descriptive statistics and Chi-squared tests are used as appropriate.
Results:
Of 102 reported events, exclusions for prior-year events, duplicates, and non-admitted patients yielded 92 unique events. Eighty-three (90%) were patient-related, and 72 included a patient with MRN representing 64 patients. Median patient age was lower than the whole-hospice median (69 years (IQR 60–79) vs. 76 years). Racial/ethnic distribution differed significantly (p<0.0001). Thirty-nine percent of safety events occurred on the day of admission and 83% within 7 days of admission. The most common event categories were Care Related (35%) and Medication Event (24%). Review of Care Related events showed 38% were miscategorized; the remaining 62% were subcategorized into groups such as “unsafe transfer” and “missing order” for greater detail.
Conclusion:
Safety events occurred predominantly early in admission and were most often care-related or medication-related. The patients experiencing events differed from the broader hospice population, including a significantly different racial and ethnic distribution. Misclassification within the reporting system highlights the need for refined hospice-specific categories. These findings support targeted education and focused attention on admission of workflows to better align safety practices with equitable, patient-centered end-of-life care.
Affiliations
Aurora St. Luke’s Medical Center, Aurora UW Medical Group, Aurora Sinai Medical Center, Aurora Zilber Family Hospice