Since April 1997, 11 sentinel events have been received and reviewed by the Joint Commission related to home health care patients who were either injured or killed as a result of a fire in the home. These home care patients were receiving supplemental oxygen service and in each case, the patient was over the age of 65. Several risk factors for home care related fires have been identified through an intensive analysis of these sentinel events; these risk factors include 1) living alone, 2) lack of smoke detectors or presence of non-functional smoke detectors, 3) cognitive impairment, 4) an identified history of smoking while oxygen is running, and 5) flammable clothing. These home care sentinel events resulted in the death of seven patients and the loss of function or permanent disfigurement for four other patients. Cigarette smoking was determined to be a contributing factor in each of these cases.