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41 Patient safety consequences of medication incidents in palliative care: mixed method analysis of incident reports
  1. Amy Brown1,
  2. Matt Wills1,
  3. Sally-Anne Francis2,
  4. Lucy Bemand-Qureshi3,
  5. Ben Bowers4,
  6. Stuart Hellard1,
  7. Antony Chuter5,
  8. Andrew Carson-Stevens1 and
  9. Sarah Yardley2,6
  1. 1Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
  2. 2Marie Curie Palliative Care Research Department, University College London, London, UK
  3. 3Barking, Havering and Redbridge University Hospitals NHS Trust
  4. 4University of Cambridge
  5. 5Patient and Public Involvement Collaborator, Hayward Heaths, UK
  6. 6Central and North West London NHS Foundation Trust, London, UK
  7. *Joint first authors


Introduction Approximately 20% of serious palliative care incidents relate to medication; these are disproportionately reported when patients are in their usual residence compared to hospitals/hospices. Continuous subcutaneous infusions (CSCIs) are implicated in around a quarter of such incidents. Over half of serious palliative care incidents resulting in police or coroner involvement following patient death relate to medication. Little is known of the underlying contributory factors (e.g. situational context, system structures, human factor issues) leading to either severe harm/death, or specifically, CSCI medication incidents.

Aims To identify and analyse underlying contributing factors in incident reports of palliative medication management in community, hospital, and hospice settings.

Method The study applies a mixed-methods approach to National Reporting and Learning System data.1 Following systematic searches, a purposive sample of 7506 eligible incidents (reported 2016-2021) are being analysed using established cross-sectional quantitative descriptive analysis (Primary Care Patient Safety (PISA) classification) and interpretative qualitative metasynthesis. Standard techniques for rigour are applied e.g. double-coding to aid consistent interpretation of data and reflexivity. An ‘expert by experience’ collaborator is helping ensure focus remains on patient/carer priorities. Ethical approval has been granted.

Results We will present analysis of two priority areas within our larger data sample: medication-related incidents resulting in severe harm or death (n=2459) and CSCI-related incidents (n=1692). Using the recursive model of incident analysis we will discuss: underlying contributing factors and interactions between these; analysis of professional perceptions of suboptimal palliative medication management; and patient safety, considering implications for system change.

Conclusion This is an innovative mixed-methods study providing high-quality nuanced understanding of ‘real-life’ challenges in patient safety for people receiving palliative care.

Impact Detailed understanding of underlying contributing factors will help clinicians appropriately target quality improvement initiatives and education to achieve change. Findings will also inform policy by providing detailed evidence for solutions to strategic system re-design.


  1. BMJ Open 2021;11:e048696. doi:10.1136/bmjopen-2021-048696

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