• Nicole Heneka, Tim Shaw, Debra Rowett, Samuel Lapkin, and Jane L Phillips.
• 1 School of Nursing, University of Notre Dame Australia , Darlinghurst, Australia .
• J Palliat Med. 2018 Jun 1; 21 (6): 825-835.

BackgroundOpioid errors have the potential to cause significant patient harm. These high-risk medications are used in high volumes in palliative care services to manage pain and other symptoms. Palliative patients are at greater risk of harm from opioid errors, as they are generally older and taking numerous medications to manage multiple comorbidities. Understanding factors contributing to opioid errors in inpatient palliative care services is a largely underexplored, yet, essential aspect of patient safety.ObjectiveTo explore and identify the characteristics and associated contributing factors of reported opioid errors in palliative care inpatient services using a multi-incident analysis framework.DesignA multi-incident analysis of opioid errors reported over three years in two Australian specialist palliative care inpatient services.ResultsA total of 78 opioid errors were reported. The majority (76%) of these errors occurred during opioid administration, primarily due to omitted dose (34%) and wrong dose (17%) errors. Eighty-five percent of reported errors reached the patient resulting in opioid underdose for over half (59%) of these patients. Over one-third (37%) of errors caused patient harm, which required clinical intervention. Error contributing factors included the following: noncompliance with policy; individual factors such as distraction; poor clinical communication systems; and workload.ConclusionsThis multi-incident analysis has provided initial insights into factors contributing to opioid errors in palliative care inpatient services. Further exploration is warranted to understand palliative care clinicians' perspectives of systems, individual, and patient factors that influence safe opioid delivery processes.

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