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Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents

Yardley, Iain, Yardley, Sarah, Williams, Huw, Carson-Stevens, Andrew ORCID: and Donaldson, Liam J 2018. Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents. Palliative Medicine 32 (8) , pp. 1353-1362. 10.1177/0269216318776846

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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. 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 the underlying causes and the nature of resultant harms. 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 12-year period, April 2002 to March 2014. 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, 8 transfer incidents, 6 suicides and 5 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. Conclusion: 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.

Item Type: Article
Date Type: Publication
Status: Published
Schools: Medicine
Publisher: SAGE Publications
ISSN: 0269-2163
Date of First Compliant Deposit: 11 June 2018
Date of Acceptance: 23 April 2018
Last Modified: 24 Oct 2022 09:53

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