Background In the UK, 20% of reported serious palliative care incidents relate to medication, a quarter of which involve continuous subcutaneous infusions (CSCIs). Multistep processes for prescription and use of CSCIs are risk-prone activities. Incident analysis provides opportunities to learn how to best improve patient safety.

Aims (1) characterise and analyse CSCI incidents in a national database to identify structural and human factor issues; (2) provide recommendations for learning and targets for system improvement.

Methods Systemic identification and analysis of CSCI incidents reported to the National Reporting and Learning System (NRLS) in England and Wales from 2016 to 2021. A cross-sectional quantitative descriptive analysis was undertaken using the PatIent SAfety (PISA) classification system, alongside an interpretive qualitative thematic analysis.

Results 1317 CSCI incidents in palliative care were identified from a purposively selected sample of 7506 incidents involving palliative care medication, stratified by reported level of harm; 49 (4%) of incidents were confirmed to result in severe harm or death, 206 (16%) in moderate harm, 1050 (79%) in low/no harm using the standardised NHS harm outcomes framework. The commonest primary incidents were administration of the wrong dose (n=248, 19%) and issues in medication timeliness (n=233, 18%). Recurring explanatory themes included inadequate continuity of care between locations and providers, lack of access to clinical expertise and barriers to following established protocols. Many reports contained multiple points of potential system failure but potential psychological harms were still commonly overlooked. Ease of timely access to medication and CSCI equipment, in addition to access to clinical expertise, are priorities for improvement.

Conclusion This detailed analysis of CSCI incidents highlights the need for system improvements to facilitate better communication and care continuity, especially when patients transition between care settings. Healthcare professionals need support to contribute high-quality descriptions of incidents to pinpoint precise system changes for improvement.