Understanding end-of-life injectable medication patient safety origin incidents in the community: a mixed-methods analysis of national incident-reporting data

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BACKGROUND: The use of injectable end-of-life symptom control medications is complex and a risk-prone healthcare activity in the community. Attention is often directed towards the immediate causes of medication-related incidents; however, valuable learning can be gained by examining 'origin incidents', the first adverse event occurring in incident chains that resulted in patient harm or the potential for harm. Understanding these origin incidents can underpin improvements in system resilience to ensure the provision of timely, effective and safe symptom management. System resilience arises from capacities at individual, team and structural levels that enable a complex system to adapt practices and maintain essential functions under varying conditions. OBJECTIVE: To understand the nature of reported origin incidents involving injectable end-of-life symptom control medication in the community and to identify how system resilience can be improved. DESIGN: Retrospective observational study and mixed-methods analysis of nationally reported community injectable medication patient safety incidents, sourced via the National Reporting and Learning System database. SETTING(S): Community-based care in England and Wales. PARTICIPANTS: A stratified random sample of 2150 incidents was screened for eligibility: 317 incident reports were included. Incident reports involving injectable end-of-life symptom control medications were included. These related to adult patients (aged 18+) receiving end-of-life care in the community, between 2017 and 2022. METHODS: Eligible incidents involved reported chains of incidents (events) influenced by an origin incident. Incident narratives were coded to classify incident types, contributory factors, patient impact and harm severity. Data analysis utilised a mixed methods approach. An initial quantitative descriptive analysis informed subsequent qualitative thematic analysis lines of inquiry. RESULTS: Ineffective and unsafe symptom control care is influenced by injectable medication origin incidents occurring across the full range of medication management processes. 67.5% (214/317) of reports described actual harm to patients. System resilience was impeded by ineffective transfers of care, difficulties sourcing timely symptom management input from clinical teams, and medication stock and supplies issues. Chains of negative incidents were often exacerbated by discontinuity of care, inadequate communication between in-hours and out-of-hours care providers, mistakes and omissions, failure to follow protocols and insufficient staffing capacity. CONCLUSIONS: Examining upstream origin incidents generated valuable system-wide insights, as these initial events influence subsequent actions and system resilience. Enhancing system resilience to support timely and safe symptom management requires improved coordination during transfers of care, reliable access to equipment and valid permission to administer charts, and adequate staffing to provide responsive, cross-organisational care.

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