Background
Opioids are used in high doses and frequency in palliative care services to manage cancer pain and other symptoms. An opioid is administered approximately every six minutes in specialist inpatient palliative care services, with reported opioid error rates of 0.9 (±1.5) opioid errors per 1000 occupied bed days. However, little is known about the factors that contribute to or mitigate opioid errors in this service type.
Aim
To identify opioid error contributory and mitigating factors, and actions required to support safe opioid delivery, in specialist inpatient palliative care.
Methods
A mixed methods study guided by a multi-incident analysis framework, and the Yorkshire Contributory Factors Framework. Five discrete but inter-related studies were undertaken: a systematic literature review; retrospective reviews of clinical incident data; and semi-structured interviews and focus groups with palliative care clinicians (n=58), in three specialist palliative care inpatient services in metropolitan NSW.
Findings
Opioid error contributing factors in specialist inpatient palliative care are multifactorial. Sub-optimal skill mix, the complexity of opioid administration, and the absence of a clinical pharmacist in the palliative care multi-disciplinary team, were key opioid error contributory factors. Conversely, a positive safety culture, a dedicated Clinical Nurse Educator, and supportive nursing practice environment were identified as critical to mitigating opioid errors. Palliative care nurses were pivotal in identifying and intercepting opioid errors, particularly prescribing errors. Error interception was facilitated by highly collaborative interdisciplinary relationships, supportive management, and organisational commitment to quality care.
Implications for practice
Supporting safe opioid delivery in specialist inpatient palliative care is contingent on: i) embedding a positive safety culture; ii) enabling an agile palliative care workforce; iii) privileging opioid education; and iv) empowering clinicians to identify, challenge and report opioid errors.
Conclusion. A positive opioid safety culture, which empowers clinicians to practise safely, and promotes a non-punitive approach to error occurrence and reporting, is critical to supporting safe opioid delivery in the palliative care context. The roles of the clinical nurse educator and pharmacist are fundamental to instilling and supporting safe opioid delivery in specialist inpatient palliative care services.