Brown Amy, Yardley Sarah, Bowers Ben, Francis Sally-Anne, Bemand-Qureshi Lucy, Hellard Stuart, Chuter Antony, Carson-Stevens Andrew
Marie Curie Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
Swansea University Medical School, Swansea University, Swansea, UK.
Palliat Med. 2025 Jan;39(1):7-21. doi: 10.1177/02692163241287639. Epub 2024 Oct 23.
About 25% of palliative medication incidents involve continuous subcutaneous infusions. Complex structural and human factor issues make these risk-prone interventions. Detailed analysis of how this safety-critical care can be improved has not been undertaken. Understanding context, contributory factors and events leading to incidents is essential.
(1) Understand continuous subcutaneous infusion safety incidents and their impact on patients and families; (2) Identify targets for system improvements by learning from recurrent events and contributory factors.
Following systematic identification and stratification by degree of harm, a mixed methods analysis of palliative medication incidents involving continuous subcutaneous infusions comprising quantitative descriptive analysis using the atent fety (PISA) classification system and qualitative narrative analysis of free-text reports.
SETTING/PARTICIPANTS: Palliative medication incidents ( = 7506) reported to the National Reporting and Learning System, England and Wales (2016-2021).
About 1317/7506 incidents involved continuous subcutaneous infusions with 943 (72%) detailing harms. Primary incidents (most proximal to patient outcomes) leading to inappropriate medication use (including not using medication when it was needed) were underpinned by breakdowns in three major medication processes: monitoring and supply (405, 31%), administration (383, 29%) and prescribing (268, 20%). Recurring contributory factors included discontinuity of care within and between settings, inadequate time, inadequate staffing and unfamiliarity with protocols. Psychological harms for patients and families were identified.
System infrastructure is needed to enable timely supply of medication and equipment, effective coordinated use of continuous subcutaneous infusions, communication and continuity of care. Training is needed to improve incident descriptions so these pinpoint precise targets for safer care.
约25%的姑息治疗用药事件涉及持续皮下输注。复杂的结构和人为因素问题使这些干预措施容易出现风险。尚未对如何改进这种对安全至关重要的护理进行详细分析。了解导致事件的背景、促成因素和事件至关重要。
（1）了解持续皮下输注安全事件及其对患者和家庭的影响；（2）通过从反复发生的事件和促成因素中学习，确定系统改进的目标。
在按伤害程度进行系统识别和分层之后，对涉及持续皮下输注的姑息治疗用药事件进行混合方法分析，包括使用阿滕特安全（PISA）分类系统进行定量描述性分析以及对自由文本报告进行定性叙述分析。
设置/参与者：向英格兰和威尔士国家报告与学习系统报告的姑息治疗用药事件（n = 7506）（2016 - 2021年）。
约1317/7506起事件涉及持续皮下输注，其中943起（72%）详细说明了伤害情况。导致用药不当（包括在需要时未使用药物）的主要事件（最接近患者结局）是由三个主要用药过程中的故障所支撑的：监测与供应（405起，31%）、给药（383起，29%）和处方开具（268起，20%）。反复出现的促成因素包括不同机构内部和之间护理的不连续性、时间不足、人员配备不足以及对方案不熟悉。确定了对患者和家庭的心理伤害。
需要系统基础设施来确保药物和设备的及时供应、持续皮下输注的有效协调使用、沟通以及护理的连续性。需要进行培训以改进事件描述，从而明确更安全护理的精确目标。
