Defining patient safety in hospice: principles to guide measurement and public reporting.

Despite progress towards safer care in most settings, there has been much less attention to improving safety in hospices, which care for more than 1,500,000 patients every year. In this article, we describe three serious conflicts that arise when safety measures from other settings are applied to hospice. First, safety measures that are imposed in order to reduce morbidity and mortality may be irrelevant for a hospice patient whose goals focus on comfort. Second, safety measures that are defined in patients with a life expectancy of years can be inappropriate for hospice patients whose typical survival is measured in days. Third, it can be very difficult to assign responsibility for the safety of hospice patients, whose care is provided mostly by family and friends. Therefore, generally accepted safety measures are often inappropriate for hospice care, and can lead to unintended consequences if they are applied without critical evaluation or modification. Instead, we suggest three principles that can guide the development of hospice-appropriate safety measures by considering a patient's goals and life expectancy, and the degree to which responsibility for a patient's care is shared.