Manual of Articles Sections 1 - 9
Section 2
Medical Errors and Patient Safety in Palliative Care:
Review of Current Literature

Question 2 | Answer Booklet | Table of Contents | Printable Page

During the past 10 years, the discussion on medical errors and patient safety has gained increasing attention both in medicine and the general public. [1–3] As a survey of the European Commission showed, 78% of the citizens of the European Union classify medical errors as a relevant problem. For the United States, the Institute of Medicine (IOM) estimated that 44,000–98,000 deaths annually are caused by medical errors and that the costs associated with preventable adverse events in the United States amount to $17–$29 billion each year.[5]

Many countries have installed national patient safety organizations and programs that are supposed to foster research, public awareness, and practice change (e.g., the National Center for Patient Safety in the United States, the National Patient Safety Agency in the United Kingdom, and the German Coalition for Patient Safety).

In medical practice, health care professionals have begun to realize that the topic of medical errors is best dealt with by frank acceptance and an endeavor to prevent errors.
           
Types of Errors in Palliative Care
Medical errors in palliative care are primarily identified in drug treatment for symptom control, particularly in opioid analgesia. It is well known that medication errors are the most prevalent type of medical errors in general.[5] So even in palliative care erroneous selection, dosage or administration of drugs can either lead to undertreatment of distressing symptoms or to intoxication, both resulting in unnecessary suffering for the patient.

In our search, we found three examples for errors leading to opioid intoxication: inadvertently administering high-dose intrathecal tramadol instead of morphine leading to myoclonus, diaphoresis, and hypotension [10]; escalating the dosage of intravenous opioids too rapidly after withdrawal from the artificial respirator, followed by sedation and respiratory depression[12]; and mixing up basal rate and bolus dose in a pump of patient-controlled analgesia, leading to lethargy of the patient.[14] Although our literature search did not yield articles on errors in the management of symptoms other than pain, it seems plausible that errors occur just as well in treating nausea, vomiting, constipation, dyspnea, delirium, or any other frequent symptom in palliative patients.

Palliative care clinicians usually encounter patients who already have been diagnosed as suffering from a specific life-limiting disease. In some cases, previous preventive or diagnostic errors of colleagues may be retrospectively detected by palliative care clinicians. The example we found was a 48-year-old patient with metastatic cervical cancer, who had shown dysplasia in a Papanicolaou test 3 years prior, which had not been followed-up or prompted a colposcopy because the treating physician moved away and the communication to the new doctor was apparently insufficient

Relevance of Medical Errors in Palliative Care
            In other medical disciplines the relevance of medical errors is obvious: Errors cause significant mortality and morbidity, prolonged hospital stays, increased health care costs, and economic losses for society in general.[5,31,32] Mortality as a main outcome measure of patient safety is difficult to use in palliative care where nearly every patient will die in a foreseeable future. Yet, patient safety is just as relevant in palliative care as it is in other medical disciplines. Morbidity, unnecessary suffering, and additional economic costs may all be associated with errors in palliative care.

In addition, errors may cause an earlier than expected death depriving the patient of the chance to experience the last phase of life, complete unfinished business, and say goodbye to his or her loved ones. On the other hand, errors in palliative care may also postpone the time of death and maybe prolong an unwanted state of suffering at the end of life.
           
There are several reasons why medical errors are relevant at the end of life and why palliative care should strive for patient safety.

--First, individuals at the end of life are more vulnerable to medical errors.[20] They are exposed to intensive and multi-drug treatment with a high risk of error,[33,34] and may suffer more harm from errors because they are frail and have less reserves. They often lack decision-making capacity[35] or even consciousness, making it difficult to identify the patient’s will, to reevaluate treatment decisions or to detect errors and the harm that is associated with them. An unconscious patient in the dying phase will not complain of pulmonary edema and ascites due to intravenous fluid overload, and relatives may not identify this problem as being the consequences of the medical error of administering too large volumes of intravenous fluids.

--Second, palliative care as a young discipline lags behind in its evidence base. The relative paucity of guidelines and standard operating procedures opens up a space for committing errors and complicates their identification especially in areas, where palliative care is not the major focus (e.g., on intensive care units or in general practitioners’ offices).

--Third, the quality of a person’s last phase of life and the way he or she dies is not only important for the biography of that person, but also for the bereaved relatives and society in general.[36] Additionally, the potential for economic losses or savings is highest in the months before a person’s death.[37,38] Thus, errors in palliative care are clearly relevant for society and warrant special clinical, educational, and research  efforts.
           
Detection and Prevention of Errors in Palliative Care
What can palliative care as a young discipline learn from this? As Berwick et al.[40] emphasized, we can only improve patient safety if we accept that we do make errors. In the United States, first steps have been made in sensitizing palliative care professionals for the topic. In their latest research agenda, the Quality Interagency Coordination Task Force of the U.S. government demanded more research and defined aims concerning errors in palliative care.[20,41]

Critical Incident Reporting Systems (CIRS) encourage health care professionals to report errors and near-misses anonymously and are used to improve quality measures in institutions or provide continuous medical education on internet platforms.[42] These systems have been used successfully used in emergency medicine, anesthesiology and surgery.[43–45]

They encourage health care professionals to anonymously report near-misses, thus facilitating professionals to learn from each other and enabling institutions to improve safety systems. It is a challenge for the next years to develop and implement a CIRS specifically designed for palliative care professionals.

--Dietz, I., Borasio, G., Schneider, G., & Jox, R. J. (2010). Medical Errors and Patient Safety in Palliative Care: A Review of Current Literature. Journal Of Palliative Medicine, 13(12), 1469-1474. doi:10.1089/jpm.2010.0228

QUESTION 2

What are three reasons medical errors are relevant in palliative care? Record the letter of the correct answer the Answer Booklet