Patients receiving palliative care are often at increased risk of unsafe care with the out-of-hours setting presenting particular challenges. This article aimed to explore the nature and causes of unsafe care from primary care services. An analysis of patient safety incident reports from the National Reporting and Learning System was carried out. A total of 1072 patient safety reports involving patients receiving sub-optimal palliative care via the out of hours primary care services were identified. Almost two-thirds of reports described harm with outcomes such as increased pain, with emotional and psychological distress featuring highly. Commonly identified contributory factors were a failure to follow protocol, lack of skills/confidence of staff and patients requiring medication via a syringe driver.
Williams, H. et al. 2018. Quality improvement priorities for safer out of hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database. Palliative Medicine, published online December 2018