More than half of palliative home care incident reports in England and Wales relate to medication errors, a new study has revealed.
The study, published in the Palliative Medicine journal, was led by Cardiff GP Dr Huw Williams and funded by Marie Curie and the Royal College of GPs.
Researchers reviewed 1,072 patient safety reports from a five-year period and found 613 were related to errors in prescribing, dispensing or administering medications.
The chain of events leading to medication incidents often included difficulties accessing timely assessments, problems locating supplies of medications, a faulty syringe driver or inefficient communication processes, researchers found.
Staff level contributory factors were common and included failure to follow agreed protocols, mistakes due to inattention or a lack of sufficient knowledge or skills.
Patient outcomes included pain, emotional distress for patients and families, and increased work for members of the healthcare team.
These incidents led to serious harm in 48 cases and to death in five cases.
A further 123 safety reports were related to problems with accessing to timely care or advice, with a quarter of these involving difficulties securing a home visit.
Ten percent (102) of the reports related to shortfalls in non-medication based treatment such as catheters; and a further 10% described issues with ensuring efficient, accurate transfer of information between healthcare teams.
Almost two-thirds of the patient safety incidents that comprised the study population resulted in “actual harm” to patients, including increased pain and emotional and psychological distress.
Serious harm (moderate harm or worse) occurred in 129 (12%) incidents, resulting in hospital admission, permanent injury or death.
Palliative care, increasingly delivered in community settings, poses unique patient safety challenges, the researchers say.
In the UK, a range of healthcare professionals, with variable training in end-of-life care practices, are required to meet a patient’s changing needs around the clock, but they often lack consistent access to clinical information and most resources go to in-hours services.
Going forward, lasting, system-level interventions, particularly those facilitating safe access to medications and treatments, more timely care for those at the end of life and information transfer across care boundaries should be the focus of future improvement initiatives, the researchers concluded.