O9 The safety consequences of care partner ‘othering’: an activity theory analysis of palliative medication management during home-hospital-hospice care transitions

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Background Effective palliative care depends on safe symptom control, requiring complex medication management across multiple care settings. Medication errors account for one-fifth of palliative serious safety incidents. Caregiving is shaped by how individuals position themselves and others within health systems. This paper examines palliative medication challenges faced by patient-nominated care partners (‘carers’). Methods Using Activity Theory as a sociocultural lens, we worked with patient and public involvement (PPIE) and stakeholder groups to explore system structures and human activity in palliative medication management. Ethnography was conducted in home, hospital, and hospice settings in London. Fieldnotes and interview transcripts underwent reflexive thematic analysis. An evidence-based toolkit was developed and refined, then applied in four systems to co-produce context-specific improvements. Results Purposive observations (120 hours) and interviews (21 patients, 11 carers, 51 professionals) revealed that distribution of labour was seldom negotiated with carers. Their ‘inside story’ was often overlooked, particularly during transitions between care settings. Carers described accidental and/or incremental entry into caregiving and received little guidance on operational norms, yet they were relied upon to mitigate risks when structural organisation of chains of activity failed. Many devised personal workarounds to ensure safe medication management. They experienced contradictory ‘othering’ of their position: their understanding, expertise, and legitimacy were questioned during hospital or hospice admissions, while in community settings they felt repositioned as a catch-all safety net. Professionals underestimated carers’ need for medication micro-decision support, yet overestimated the relief provided by professional takeover. Insufficient attention to medication management following bereavement added to carers’ distress. Conclusions Implicit rules and differing mental models left carer roles and responsibilities ambiguous, undermining good medication management, compromising safety, and reducing confidence. Our toolkit fosters dialogue and shared solutions by encouraging recognition of carers as integral members of the care team and offering guidance for carers to co-design medication management.

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