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46 Patient safety in palliative care: a mixed methods study of reports to a national database of serious incidents
  1. Iain Yardley1,2,
  2. Sarah Yardley3,4,5,
  3. Huw Williams6,
  4. Andrew Carson-Stevens6,7,8 and
  5. Liam J Donaldson9
  1. 1Department of Paediatric Surgery, Evelina London Children’s Hospital, London, UK
  2. 2King’s College, London, UK
  3. 3Central and North West London NHS Foundation Trust, London, UK
  4. 4Marie Curie Palliative Care Research Department, University College London, London, UK
  5. 5Medical Education, Keele University Medical School, Keele, UK
  6. 6Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
  7. 7Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
  8. 8Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
  9. 9Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK


Background Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population.

Aim To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care.

Setting and participants Reports to a national database of ‘serious incidents requiring investigation’ involving patients receiving palliative care in the National Health Service (NHS) in England during the twelve year period April 2002 to March 2014.

Design A mixed methods approach was used. Following quantification of type of incidents and their location a qualitative analysis using a modified framework method was used to interpret themes in reports to examine underlying causes and the nature of resultant harms.

Results A total of 475 reports were identified: 266 related to pressure ulcers 91 to medication errors 46 to falls 21 to healthcare associated infections (HCAIs) 18 were other instances of disturbed dying 14 were allegations against health professions eight transfer incidents six suicides and five other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience under-resourcing and poor service coordination. Resultant harms included worsened symptoms disrupted dying serious injury and hastened death.

Conclusions Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.

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