Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis.

Medication errors can occur at many points along the medication administration pathway, and continuous subcutaneous infusions are particularly risk prone. This study analyzed medication error reports involving palliative care continuous subcutaneous infusions submitted to the National Reporting and Learning System, England and Wales, from 2016 to 2021. Approximately 72% described harms with breakdowns occurring in three processes: monitoring and supply, administration, and prescribing. Potential system-based solutions were proposed to replace human-based solutions.