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Section 2
Medical Errors and Patient Safety in Palliative Care:
Review of Current Literature

Question 2 | Test | Table of Contents

During the past 10 years, the discussion on medical errors and patient safety has gained increasing attention both in medicine and the general public. [1–3] As a survey of the European Commission showed, 78% of the citizens of the European Union classify medical errors as a relevant problem. For the United States, the Institute of Medicine (IOM) estimated that 44,000–98,000 deaths annually are caused by medical errors and that the costs associated with preventable adverse events in the United States amount to $17–$29 billion each year.[5]

Many countries have installed national patient safety organizations and programs that are supposed to foster research, public awareness, and practice change (e.g., the National Center for Patient Safety in the United States, the National Patient Safety Agency in the United Kingdom, and the German Coalition for Patient Safety).

In medical practice, health care professionals have begun to realize that the topic of medical errors is best dealt with by frank acceptance and an endeavor to prevent errors.
Types of Errors in Palliative Care
Medical errors in palliative care are primarily identified in drug treatment for symptom control, particularly in opioid analgesia. It is well known that medication errors are the most prevalent type of medical errors in general.[5] So even in palliative care erroneous selection, dosage or administration of drugs can either lead to undertreatment of distressing symptoms or to intoxication, both resulting in unnecessary suffering for the patient.

In our search, we found three examples for errors leading to opioid intoxication: inadvertently administering high-dose intrathecal tramadol instead of morphine leading to myoclonus, diaphoresis, and hypotension [10]; escalating the dosage of intravenous opioids too rapidly after withdrawal from the artificial respirator, followed by sedation and respiratory depression[12]; and mixing up basal rate and bolus dose in a pump of patient-controlled analgesia, leading to lethargy of the patient.[14] Although our literature search did not yield articles on errors in the management of symptoms other than pain, it seems plausible that errors occur just as well in treating nausea, vomiting, constipation, dyspnea, delirium, or any other frequent symptom in palliative patients.

Palliative care clinicians usually encounter patients who already have been diagnosed as suffering from a specific life-limiting disease. In some cases, previous preventive or diagnostic errors of colleagues may be retrospectively detected by palliative care clinicians. The example we found was a 48-year-old patient with metastatic cervical cancer, who had shown dysplasia in a Papanicolaou test 3 years prior, which had not been followed-up or prompted a colposcopy because the treating physician moved away and the communication to the new doctor was apparently insufficient

Relevance of Medical Errors in Palliative Care
In other medical disciplines the relevance of medical errors is obvious: Errors cause significant mortality and morbidity, prolonged hospital stays, increased health care costs, and economic losses for society in general.[5,31,32] Mortality as a main outcome measure of patient safety is difficult to use in palliative care where nearly every patient will die in a foreseeable future. Yet, patient safety is just as relevant in palliative care as it is in other medical disciplines. Morbidity, unnecessary suffering, and additional economic costs may all be associated with errors in palliative care.

In addition, errors may cause an earlier than expected death depriving the patient of the chance to experience the last phase of life, complete unfinished business, and say goodbye to his or her loved ones. On the other hand, errors in palliative care may also postpone the time of death and maybe prolong an unwanted state of suffering at the end of life.
There are several reasons why medical errors are relevant at the end of life and why palliative care should strive for patient safety.

--First, individuals at the end of life are more vulnerable to medical errors.[20] They are exposed to intensive and multi-drug treatment with a high risk of error,[33,34] and may suffer more harm from errors because they are frail and have less reserves. They often lack decision-making capacity[35] or even consciousness, making it difficult to identify the patient’s will, to reevaluate treatment decisions or to detect errors and the harm that is associated with them. An unconscious patient in the dying phase will not complain of pulmonary edema and ascites due to intravenous fluid overload, and relatives may not identify this problem as being the consequences of the medical error of administering too large volumes of intravenous fluids.

--Second, palliative care as a young discipline lags behind in its evidence base. The relative paucity of guidelines and standard operating procedures opens up a space for committing errors and complicates their identification especially in areas, where palliative care is not the major focus (e.g., on intensive care units or in general practitioners’ offices).

--Third, the quality of a person’s last phase of life and the way he or she dies is not only important for the biography of that person, but also for the bereaved relatives and society in general.[36] Additionally, the potential for economic losses or savings is highest in the months before a person’s death.[37,38] Thus, errors in palliative care are clearly relevant for society and warrant special clinical, educational, and research  efforts.
Detection and Prevention of Errors in Palliative Care
What can palliative care as a young discipline learn from this? As Berwick et al.[40] emphasized, we can only improve patient safety if we accept that we do make errors. In the United States, first steps have been made in sensitizing palliative care professionals for the topic. In their latest research agenda, the Quality Interagency Coordination Task Force of the U.S. government demanded more research and defined aims concerning errors in palliative care.[20,41]

Critical Incident Reporting Systems (CIRS) encourage health care professionals to report errors and near-misses anonymously and are used to improve quality measures in institutions or provide continuous medical education on internet platforms.[42] These systems have been used successfully used in emergency medicine, anesthesiology and surgery.[43–45]

They encourage health care professionals to anonymously report near-misses, thus facilitating professionals to learn from each other and enabling institutions to improve safety systems. It is a challenge for the next years to develop and implement a CIRS specifically designed for palliative care professionals.

--Dietz, I., Borasio, G., Schneider, G., & Jox, R. J. (2010). Medical Errors and Patient Safety in Palliative Care: A Review of Current Literature. Journal Of Palliative Medicine, 13(12), 1469-1474. doi:10.1089/jpm.2010.0228

Personal Reflection Exercise #2
The preceding section contained information about medical errors in palliative care.  Write one case study example regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Ferrer, R. A., Padgett, L., & Ellis, E. M. (2016). Extending emotion and decision-making beyond the laboratory: The promise of palliative care contexts. Emotion, 16(5), 581–586.

Kasl-Godley, J. E., King, D. A., & Quill, T. E. (2014). Opportunities for psychologists in palliative care: Working with patients and families across the disease continuum. American Psychologist, 69(4), 364–376.

Leroy, H., Dierynck, B., Anseel, F., Simons, T., Halbesleben, J. R. B., McCaughey, D., Savage, G. T., & Sels, L. (2012). Behavioral integrity for safety, priority of safety, psychological safety, and patient safety: A team-level study. Journal of Applied Psychology, 97(6), 1273–1281.

Yu, J. A., Schenker, Y., Maurer, S. H., Cook, S. C., Kavlieratos, D., & Houtrow, A. (2019). Pediatric palliative care in the medical neighborhood for children with medical complexity. Families, Systems, & Health, 37(2), 107–119.

What is one reason medical errors are relevant in palliative care? To select and enter your answer go to Test.

Section 3
Table of Contents

Excerpts from Bibliography referenced in this article
1. Reason J: Human error: Models and management. West J Med 2000;172:393–396.
2. Leape LL, Berwick DM: Five years after To Err Is Human: What have we learned? JAMA 2005;293:2384–2390.
3. Henderson WA: Blundering hospitals ‘kill 40,000 a year.’ Times Online 2004. news/uk/health/article469178.ece
5. Kohn LT, Coorigan Jm, Donaldson MS (eds): To Err is Human. Building a Safer Health System. Washington, D.C.: Natoinal Academy Press. 1999.
10. Barrett NA, Sundaraj SR: Inadvertent intrathecal injection of tramadol. Br J Anaesth 2003;91:918–920.
12. Blinderman CD: Opioids, iatrogenic harm and disclosure of medical error. J Pain Symptom Manage 2010;39:309–313.
14. Cohen MR: Medication errors. Nursing 1990;20:15.
20. Myers SS, Lynn J: Patients with eventually fatal chronic illness: their importance within a national research agenda on improving patient safety and reducing medical errors. J Palliat Med 2001;4:325–332.
31. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP: Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997;277:301–306.
32. Weingart SN, Mc LWR, Gibberd RW, Harrison B: Epidemiology of medical error. West J Med 2000;172:390–393.
33. Currow DC, Stevenson JP, Abernethy AP, Plummer J, Shelby-James TM: Prescribing in palliative care as death approaches. J Am Geriatr Soc 2007;55:590–595.
34. Al-Shahri MZ, Molina EH, Oneschuk D: Medication-focused approach to total pain: poor symptom control, polypharmacy, and adverse reactions. Am J Hosp Palliate Care 2003;20:307–310.
35. Casarett DJ: Assessing decision-making capacity in the setting of palliative care research. J Pain Symptom Manage 2003;25:S6–13.
36. Bowling A: Health care rationing: The public’s debate. BMJ 1996;312:670–674.
37. Lubitz JD, Riley GF: Trends in Medicare payments in the last year of life. N Engl J Med 1993;328:1092–1096.
38. Zweifel P, Felder S, Meiers M: Ageing of population and health care expenditure: A red herring? Health Econ 1999;8:485–496.
41. Report of the Quality Interagency Coordination Task Force (QuIC) to the President: Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. 2000, pp. 95.
42. Leape LL: Reporting of adverse events. N Engl J Med 2002;347:1633–1638.
43. Kram R: Critical incident reporting system in emergency medicine. Curr Opin Anaesthesiol 2008;21:240–244.
44. McCafferty MH, Polk HC, Jr.: Patient safety and quality in surgery. Surg Clin North Am 2007;87:867–881,vii.
45. Staender S, Davies J, Helmreich B, Sexton B, Kaufmann M: The anaesthesia critical incident reporting system: An experience based database. Int J Med Inform 1997;47:87–90.