Learning from end-of-life injectable medication patient safety incidents in the community: a mixed-methods analysis

Bowers, Ben, Gwyn, Sioned, Yardley, Sarah, Hellard, Stuart, Clarkson, John, McFadzean, Isobel J., Pollock, Kristian, Barclay, Stephen and Carson-Stevens, Andrew 2025. Learning from end-of-life injectable medication patient safety incidents in the community: a mixed-methods analysis. British Journal of General Practice , BJGP.2025.0106. 10.3399/bjgp.2025.0106

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Abstract

Background Processes to implement injectable end-of-life symptom control medications in the community are complex and can adversely impact patient safety. Recurring patient safety incident types and their contributory factors remain under-recognised, inhibiting system-wide learning. Aims To understand injectable end-of-life symptom control medication incidents, their contributory factors and impact on patients/families; to identify priority areas for improving safe, effective and timely care. Design and setting Mixed-methods analysis of nationally reported injectable medication patient safety incidents involving adults in the community, between 2017-2022. Methods Mixed-methods: A stratified random sample of 2150 incidents from the National Reporting and Learning System was screened for eligibility. We included and analysed incidents that involved end-of-life injectable medications in the community. Coding was undertaken to classify incident types, the contributory factors involved, patient impact and harm severity. An iterative thematic analysis was then conducted to identify patterns between recurring incident types and contributory factors. Results 419 patient safety reports detailed injectable medication-related patient safety incidents: 59.7% of incidents (250/419) described harm to patients. Frequently reported patient safety incidents included: medication administration issues (49.2%, 206/419); delayed and inadequate assessments (10.3%, 43/419); and prescription issues (8.6%, 36/419). Incidents often involved multiple services and delays. Recurrent, and often interacting, contributory factors included inadequate continuity of care, distractions and mistakes, poor equipment design and insufficient staffing levels. Conclusion Interventions to improve injectable end-of-life symptom control care should focus on ensuring timely access to assessments and prescriptions, enhancing continuity of care, and mechanisms to ensure rapid visits to administer medication.

Item Type:	Article
Date Type:	Published Online
Status:	In Press
Schools:	Schools > Medicine
Publisher:	Royal College of General Practitioners
ISSN:	0960-1643
Date of Acceptance:	6 August 2025
Last Modified:	07 Oct 2025 09:45
URI:	https://orca.cardiff.ac.uk/id/eprint/181511

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