The PSNet Collection

Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening.

Save to Library

Baim-Lance A, Ferreira KB, Cohen HJ, et al. J Gen Intern Med. 2022;Epub May 17.

When serious adverse events such as death are reported, they are typically associated with poor patient safety. In some fields of care, however, such as palliative care, deaths are expected and not necessarily an indicator of poor quality. This commentary describes how serious and non-serious adverse events (SAEs/AEs) are currently defined and reported, the associated challenges, and proposes a new approach to reporting SAE/AE in clinical trials. A decision-tree to determine SAE/AE reporting based on the new proposed approach is presented.

A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.

Save to Library

March 31, 2022

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care

Save to Library

November 30, 2021

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role

TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life care?

Save to Library

Mirarchi FL, Cammarata C, Cooney TE, et al. J Patient Saf. 2021;17:458-466.

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.

Safety in pediatric hospice and palliative care: a qualitative study.

Save to Library

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.

Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error.

Save to Library

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.

TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records.

Save to Library

Mirarchi FL, Juhasz K, Cooney TE, et al. J Patient Saf. 2019;15:230-237.

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.

Clinicians' perceptions of opioid error–contributing factors in inpatient palliative care services: a qualitative study.

Save to Library

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.

No shortcuts to safer opioid prescribing.

Save to Library

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.

Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database.

Save to Library

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.

Performing an inadvertent procedure.

Save to Library

Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.

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.

Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents.

Save to Library

Yardley I, Yardley S, Williams H, et al. Palliat Med. 2018;32:1353-1362.

The frequency and nature of adverse events experienced by patients receiving palliative care remains unknown. In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving palliative care from a national database in England over a 12-year period. They found that pressure ulcers, medication errors, and falls were the most frequently reported types of events and conclude that there is significant opportunity to improve the safety of palliative care.

An Untimely End Despite End-of-Life Care Planning

Save to Library

August 1, 2018

Hospitalized in the ICU after cardiac arrest and loss of cardiac function for 15 minutes, an older man experienced worsening neurological status. After extensive discussions about goals of care, the family agreed to a DNR order. Over the next week, his condition declined, and the family decided to transition to comfort measures. Orders were written but shortly thereafter, the family spoke with the ICU resident and reversed their decision. The resident canceled the terminal extubation orders without communicating the order change to other team members.

Dying in the Hospital With Advanced Dementia

Save to Library

December 1, 2017

Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder.

A piece of my mind. Despite my best intentions.

Save to Library

Kahn JS. JAMA. 2017;318.

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.

The lost art of doctoring: reflections of a pediatric resident.

Save to Library

Mitchell SM. JAMA Pediatr. 2018;172:10.

There are challenges to preparing residents for both the clinical and nontechnical demands of independent practice. This commentary discusses resident training and orientation to end-of-life care and consultation. The author advocates for medical education to help residents build skills to communicate with empathy and provide debriefings to address the emotional toll associated with palliative care. A recent WebM&M commentary explores the balance between comfort and harm in palliative care.

'No one is coming': hospice patients abandoned at death's door.

Save to Library

Aleccia J; Bailey M.

Patient safety in ambulatory hospice care is ill defined. Reporting on safety concerns associated with hospice care, including poor coordination and insufficient family education, this news article discusses how citizen complaints led to government investigations into deficiencies of end-of-life home care.

Engaging Seriously Ill Older Patients in Advance Care Planning

Save to Library

April 1, 2017

When a 94-year-old woman presented for routine primary care, the intern caring for her discovered that the patient's code status was "full code" and that there was no documentation of discussions regarding her wishes for end-of-life care. The intern and his supervisor engaged the patient in an advance care planning discussion, during which she clarified that she would not want resuscitation or life-prolonging measures.

The Empty Bag

Save to Library

December 1, 2016

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

Patients' perception of types of errors in palliative care—results from a qualitative interview study.

Save to Library

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.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users