Revealing the hidden harms in end-of-life care: a mixed-methods characterisation of reported safety incidents involving injectable symptom control medication

Background: Many patients dying in the community are prescribed injectable medications and are vulnerable to unsafe care. Developing safer and effective healthcare systems requires learning from patient safety incidents, including those resulting in no harm or near misses. However, health systems typically must prioritise learning from harmful incidents due to resource constraints and are at risk of missing key learning. Aims: To appraise the nature and outcomes of reported ‘no harm’ injectable end-of-life symptom control medication incidents, and understand the characteristics of those incidents and how they differ from those reclassified during the study analysis as ‘harmful’. Design and setting: Mixed-methods analysis of nationally reported (England and Wales) patient safety incidents to the National Reporting and Learning System (NRLS) involving injectable end-of-life symptom control medications in the community. Method: A random sample of 1000 reported ‘no harm’ incidents submitted between 2017 and 2022 was screened. The PatIent SAfety (PISA) Classification system was used to characterise incident type, contributory factors, reported harms and outcomes, with subsequent thematic analysis of free-text narratives. Results: 388 incidents were included. 107 (28%) reports described harm to patients and families: 43 detailed psychological harms. Comparing incidents reclassified as harmful with the true ‘no harm’ incidents, the harmful incidents contained more conflicting views between professionals and family members, and there was clear variability in perceptions of what constitutes a harm. Conclusion: Healthcare teams need to incorporate the impact on patient and families when reporting and learning from end-of-life symptom control incidents, notably resultant emotional and psychological harms.