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

[UK] Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: A mixed methods analysis
Palliative Medicine; Amy Brown, Sarah Yardley, Ben Bowers, Sally-Anne Francis, Lucy Bemand-Qureshi, Stuart Hellard, Antony Chuter, Andrew Carson-Stevens; 10/24
About 25% of palliative medication incidents involve continuous subcutaneous infusions. 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 ... administration ... and prescribing ... 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. System infrastructure is needed to enable timely supply of medication and equipment, effective coordinated use of continuous subcutaneous infusions, communication and continuity of care.