The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
Pestian T, Thienprayoon R, Grossoehme D, et al. Pediatr Qual Saf. 2020;5:e328.
The authors used qualitative data to evaluate parental perspectives of quality in pediatric home-based hospice and palliative care (HBHPC) programs, and how parents define “safe care” in the home. Thematic analysis identified eight domains of safety prioritized by patients, including an emphasis on the safety of the physical environment, medication safety, maintaining comfort and preventing harm, and trust in the HBHPC caregivers.
Gallagher R, Passmore MJ, Baldwin C. Med Hypotheses. 2020;142:109727.
The authors of this article suggest that offering palliative care services earlier should be considered a patient safety issue. They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). The patients in two of the cases were never offered palliative care services, and this could be considered a medical error – had they been offered palliative care services, they may have changed their mind about MAiD, as did the patient in the third case study.
This single-center study found that Do-Not-Resuscitate (DNR) orders and Physician Orders for Life-Sustaining Treatment (POLSTs) created at hospital admission often do not reflect the true wishes of patients and their caregivers. When queried by study staff, 44% of patients expressed wishes for life-sustaining treatment that differed from their designated code status; this resulted in revocation of the DNR order in more than one-third of patients with a discrepancy. A prior study argued that inaccurate documentation of patient's wishes for end-of-life care should be considered a medical error.
Heneka N, Bhattarai P, Shaw T, et al. Palliat Med. 2019;33:430-444.
This focus group study of Australian palliative care providers examined risk factors for opioid errors among palliative patients. They identified clinician inexperience, the drug preparation environment, and poor communication as contributory factors for medication errors. The authors conclude that multiple interventions will be needed to enhance opioid safety in palliative care.
Dowell D, Haegerich T, Chou R. N Engl J Med. 2019;380:2285-2287.
Improving opioid prescribing is a complex challenge that requires multipronged approaches to achieve safe patient pain management. This commentary offers insights to help organizations effectively implement the Centers for Disease Control and Prevention guideline and notes how misapplication of recommendations have resulted in unintended consequences such as patient harm.
Williams H, Donaldson SL, Noble S, et al. Palliat Med. 2019;33:346-356.
Patients receiving palliative care are often medically complex and may be at increased risk for safety events, especially when cared for outside of routine clinic hours. In this mixed-methods study, researchers analyzed patient safety incident reports regarding patients who received inadequate palliative care during nights and weekends from primary care services in the United Kingdom. Incidents related to medications were common, accounting for 613 out of the 1072 safety events included in the study.
The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.
End-of-life care can be difficult for patients, families, and the care team. This commentary offers insights from a physician's experience with a conversation that was psychologically detrimental to a patient and his family. The author suggests that focusing on the empathetic relationship with patients and families can provide the support needed to care for the patient while exercising judgement and engaging in shared decision making about next steps.
Kiesewetter I, Schulz C, Bausewein C, et al. BMC Palliat Care. 2016;15:75.
Adverse events in palliative care differ from those in other environments. This qualitative interview study of patients who received palliative care identified errors specific to this setting, including deviation from a patient's advance directive and error in prognosis. A recent WebM&M commentary discussed challenges to implementing advance directives.
Dietz I, Plog A, Jox RJ, et al. J Palliat Med. 2014;17:331-7.
This survey of palliative care workers in Germany sought to identify common medical errors in this setting. The majority of errors were related to communication, system failures, and medication administration, including opioid overdose.
Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.
Dietz I, Borasio GD, Molnar C, et al. J Palliat Med. 2013;16:74-81.
Patients receiving palliative care can be medically complex and often require medications considered high-risk (such as opioid pain medications). These factors are known to be associated with an increased risk of medical errors, but thus far, few studies have examined patient safety risks in palliative care patients. This survey of palliative medicine physicians in Germany found that most considered errors to be a significant problem in palliative care, and respondents cited medication errors and errors related to communication as the most common types of patient safety problems in the field. An AHRQ WebM&M case discusses a preventable adverse event that occurred in a palliative care patient.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.