@article{ref1,
title="Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents",
journal="Palliative medicine",
year="2018",
author="Yardley, Iain and Yardley, Sarah and Williams, Huw and Carson-Stevens, Andrew and Donaldson, Liam J.",
volume="32",
number="8",
pages="1353-1362",
abstract="BACKGROUND: Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. <br><br>AIM: To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. <br><br>DESIGN: A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. SETTING AND PARTICIPANTS: Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. <br><br>RESULTS: A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. <br><br>CONCLUSION: Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.<p /> <p>Language: en</p>",
language="en",
issn="0269-2163",
doi="10.1177/0269216318776846",
url="http://dx.doi.org/10.1177/0269216318776846"
}