Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: A mixed methods analysis

Brown, Amy, Yardley, Sarah, Bowers, Ben, Francis, Sally-Anne, Bemand-Qureshi, Lucy, Hellard, Stuart, Chuter, Antony and Carson-Stevens, Andrew ORCID: https://orcid.org/0000-0002-7580-7699 2024. Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: A mixed methods analysis. Palliative Medicine 10.1177/02692163241287639

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Abstract

Background: About 25% of palliative medication incidents involve continuous subcutaneous infusions. Complex structural and human factor issues make these risk-prone interventions. Detailed analysis of how this safety-critical care can be improved has not been undertaken. Understanding context, contributory factors and events leading to incidents is essential. Aims: (1) Understand continuous subcutaneous infusion safety incidents and their impact on patients and families; (2) Identify targets for system improvements by learning from recurrent events and contributory factors. Design: Following systematic identification and stratification by degree of harm, a mixed methods analysis of palliative medication incidents involving continuous subcutaneous infusions comprising quantitative descriptive analysis using the PatIent SAfety (PISA) classification system and qualitative narrative analysis of free-text reports. Setting/participants: Palliative medication incidents ( n = 7506) reported to the National Reporting and Learning System, England and Wales (2016–2021). Results: About 1317/7506 incidents involved continuous subcutaneous infusions with 943 (72%) detailing harms. Primary incidents (most proximal to patient outcomes) leading to inappropriate medication use (including not using medication when it was needed) were underpinned by breakdowns in three major medication processes: monitoring and supply (405, 31%), administration (383, 29%) and prescribing (268, 20%). Recurring contributory factors included discontinuity of care within and between settings, inadequate time, inadequate staffing and unfamiliarity with protocols. Psychological harms for patients and families were identified. Conclusions: System infrastructure is needed to enable timely supply of medication and equipment, effective coordinated use of continuous subcutaneous infusions, communication and continuity of care. Training is needed to improve incident descriptions so these pinpoint precise targets for safer care.

Item Type:	Article
Date Type:	Published Online
Status:	In Press
Schools:	Medicine
Publisher:	SAGE Publications
ISSN:	0269-2163
Date of First Compliant Deposit:	6 November 2024
Last Modified:	06 Nov 2024 10:00
URI:	https://orca.cardiff.ac.uk/id/eprint/173675

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