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

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Background Processes to implement injectable end-of-life symptom control medications in the community are complex and can have an adverse impact on patient safety. Recurring patient safety incident types and their contributory factors remain underrecognised, inhibiting system-wide learning. Aim To understand injectable end-of-life symptom control medication incidents, their contributory factors, the impact on patients/families, and 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 in England and Wales between 2017 and 2022. Method A stratified random sample of 2150 incidents from the National Reporting and Learning System were screened for eligibility. Incidents that involved end-of-life injectable medications in the community were included and analysed. Deductive coding was undertaken to classify incident types, the contributory factors involved, the impact on the patient, and harm severity. An iterative thematic analysis was then conducted to identify patterns between recurring incident types and contributory factors. Results In total, 419 patient safety reports detailed injectable medication-related patient safety incidents: 59.7% ( n = 250) of incidents described harm to patients. Frequently reported patient safety incidents included: medication administration issues (49.2%, n = 206); delayed and inadequate assessments (10.3%, n = 43); and prescription issues (8.6%, n = 36). 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.

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