“Please Describe from Your Point of View a Typical Case of an Error in Palliative Care”: Qualitative Data from an Exploratory Cross-Sectional Survey Study among Palliative Care Professionals

Abstract

Data showed that medical errors in palliative care, as seen by professionals in the field, primarily affect medication and communication, and miscommunication and system failures are perceived as the leading causes of errors. A better understanding of the characteristics of errors within palliative care and further qualitative research are warranted to prevent errors and enhance patient safety.

The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study

“…The most common form of disagreement, potential overtreatment, is when the patient expresses a desire not to be resuscitated but CPR is ordered (or assumed to be ordered) in the medical record. These findings are consistent with other reports in the literature in other clinical settings that document significant overtreatment at the EOL due principally to poor communication 9 10. This discordance has significant potential for harming patients (and their families) and is inconsistent with patient-centred care.…”

Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents

“…3 Palliative care is not immune to these risks; the use of strong opioids and sedatives, 4 care outside specialist settings, 5 reliance on informal carers 6 and promoting patient choice 7 all contribute to the risk of adverse events occurring. The fragile physical, psychological, social and spiritual state of palliative care patients reduces their resilience to unsafe care [7][8][9][10] and it is also apparent that the changing goals of therapy towards the end of life may create conflicts with measures to prevent adverse events such as pressure sores and falls that are considered standard in other areas of healthcare. 3 When asked about patient safety, patients receiving palliative care identify specific risks with poor communication, hastened death and the failure to provide a good death identified as potential harms.…”

Exploring Factors Contributing to Medication Errors with Opioids in Australian Specialist Palliative Care Inpatient Services: A Multi-Incident Analysis

“…17 Medication safety with opioids has been identified as a palliative care patient safety priority. [17][18][19] Despite the high volume of opioid use in this speciality, 11 and the heightened risk of exposure to and harm from opioid errors in this patient population, medication errors with opioids in palliative care services is a relatively unexplored area of patient safety. [19][20][21] The aims of this study were to explore and identify the characteristics and associated contributing factors of reported opioid errors in palliative care inpatient services using a multi-incident analysis framework.…”