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Opioid errors in inpatient palliative care services: a retrospective review
  1. Nicole Heneka1,
  2. Tim Shaw2,
  3. Debra Rowett3,
  4. Samuel Lapkin4 and
  5. Jane L Phillips5
  1. 1School of Nursing, University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
  2. 2Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
  3. 3School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
  4. 4Centre for Research in Nursing and Health, St George Hospital, Kogarah, New South Wales, Australia
  5. 5Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Nicole Heneka, School of Nursing, University of Notre Dame Australia, Darlinghurst, NSW 2010, Australia; nicole.heneka1{at}


Opioids are a high-risk medicine frequently used to manage palliative patients’ cancer-related pain and other symptoms. Despite the high volume of opioid use in inpatient palliative care services, and the potential for patient harm, few studies have focused on opioid errors in this population.

Objectives To (i) identify the number of opioid errors reported by inpatient palliative care services, (ii) identify reported opioid error characteristics and (iii) determine the impact of opioid errors on palliative patient outcomes.

Methods A 24-month retrospective review of opioid errors reported in three inpatient palliative care services in one Australian state.

Results Of the 55 opioid errors identified, 84% reached the patient. Most errors involved morphine (35%) or hydromorphone (29%). Opioid administration errors accounted for 76% of reported opioid errors, largely due to omitted dose (33%) or wrong dose (24%) errors. Patients were more likely to receive a lower dose of opioid than ordered as a direct result of an opioid error (57%), with errors adversely impacting pain and/or symptom management in 42% of patients. Half (53%) of the affected patients required additional treatment and/or care as a direct consequence of the opioid error.

Conclusion This retrospective review has provided valuable insights into the patterns and impact of opioid errors in inpatient palliative care services. Iatrogenic harm related to opioid underdosing errors contributed to palliative patients’ unrelieved pain. Better understanding the factors that contribute to opioid errors and the role of safety culture in the palliative care service context warrants further investigation.

  • palliative care
  • opioid
  • medication errors
  • incident reporting
  • patient safety
  • hospice care

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  • Contributors All authors contributed to the design of the review. NH undertook the data collection and all authors participated in data analysis. All authors have critically reviewed the manuscript and given approval to submit the final version.

  • Funding This work was supported by an Australian government, Collaborative Research Networks (CRN) programme scholarship (NH).

  • Competing interests None declared.

  • Ethics approval The review was approved by the hospital and University Human Research Ethics Committees.

  • Provenance and peer review Not commissioned; externally peer reviewed.