“Please Describe from Your Point of View a Typical Case of an Error in Palliative Care”: Qualitative Data from an Exploratory Cross-Sectional Survey Study among Palliative Care Professionals

Abstract

Context:

Patient safety is a concern in medicine, and the prevention of medical errors remains a challenge. The definition and understanding of an error is particularly difficult in palliative care, with scarce empirical evidence about the nature and causes of medical errors in that discipline.

Objectives:

This study explored incidents palliative care professionals perceive as typical errors in their practice, and descriptions of such events.

Methods:

In the context of an exploratory, cross-sectional survey on errors in palliative care among professionals of palliative care institutions in Bavaria, Germany (n=168), participants described a typical case in which an error occurred. Data from free-text answers was qualitatively analyzed, and categories for areas and causes of errors were extracted.

Results:

The questionnaire was returned by 42% (n=70) of the sample. Two-thirds of respondents (n=46, 66%) gave a free-text answer describing a typical error in palliative care. Seven potential areas for errors were identified in the qualitative analysis: drug treatment, palliative sedation, communication, care organization, treatment plan, end-of-life care, and history taking. Six categories emerged as causes of errors: miscommunication, system failure, dysfunctional attitudes, lack of knowledge, wrong use of technology, and misjudgement.

Conclusion:

Data showed that medical errors in palliative care, as seen by professionals in the field, primarily affect medication and communication, and miscommunication and system failures are perceived as the leading causes of errors. A better understanding of the characteristics of errors within palliative care and further qualitative research are warranted to prevent errors and enhance patient safety.

Introduction

Medical errors are known to contribute significantly to mortality, morbidity, and patient distress.^1–3 Worldwide initiatives to enhance patient safety have grown in recent years, in the clinical, legal, policy, and empirical research levels.^4–6 Many attempts undertaken over the last decade were proven to be effective in reducing adverse events and improving patient outcomes.⁷ Nevertheless, handling of medical errors remains a challenge.

To create adequate strategies for the handling and prevention of medical errors, it is crucial to understand their causes and natures, and to know the systems in which they occur. The first scientific exploration from a clinical research perspective dates back to the 1990s, with current research being carried out in a more specific way for different types of errors, medical disciplines, and patient populations.^8–10 Table 1 shows an often-cited concept for categorizing medical errors, which is a model based in the research by Leape and colleagues.⁸

Table 1.

Categorization of Different Types of Medical Errors According to Leape et al. ⁸

Type of error	Examples
Performance	Technical error, delay in treatment, using inappropriate form of therapy
Prevention	Failure to use indicated tests, failure to take precaution to prevent accidental therapy
Diagnosis	Use of inappropriate or outmoded diagnostic test, physician, or other professional practicing outside area of expertise
Drug treatment	Error in dose or method of use, failure to recognize drug-drug interaction, use of inappropriate drug
System	Inadequate reporting or communication, inadequate monitoring system, inadequate training or supervision
Other	Any type of error not listed above

Patients in palliative care and end-of-life care are known to be particularly vulnerable to medical errors. This is partly explained by an increased exposure to medical treatment during the last months of life, decreasing physical and cognitive resources for self-protection and the capacity for clinical decision making, and a higher likelihood of being treated within a nonevidence-based concept of care.¹¹ Currow and colleagues underlined the importance of active monitoring for symptomatic adverse events in palliative care and defined such events as “an undesirable or unintended occurrence subsequent to a clinical intervention…that renders symptoms, distress, or irreversible deterioration for the patient…and that may indicate that a person has received poor-quality health care.”¹²

There is little empirical evidence in the literature as to what constitutes the nature and causes of medical errors specific to palliative care, and there seem to be added complexities and difficulties in defining such events or processes in this clinical specialty.¹³ In prior work we identified that in addition to errors from clinical interventions or medication errors (areas of attention in prior empirical work by others), errors in communication seem to play a particularly important role in palliative care.¹⁴ We argued that for a systematic approach towards a framework of error prevention in palliative care, a shared general and comprehensive understanding of what we are actually referring to and looking for when we say “error in palliative care” is first and foremost important. Drawing from the same survey sample of interprofessional health care providers in palliative care, we wanted to comprehend, using a qualitative approach, what these professionals understand and describe as errors in palliative care. The objective of this study was, therefore, to explore what palliative care professionals perceive as a typical error in their practice and how they describe such events.

Methods

Data collection

This study presents the qualitative data from a larger cross-sectional survey reported elsewhere.¹⁴ Over a three-month period in 2010, we conducted a semiquantitative, anonymous survey among palliative care professionals in the German region of Bavaria (12.5 million inhabitants). The study was supported by the German Society for Palliative Medicine. Fifty-six relevant institutions (40 inpatient specialist palliative care units, 11 inpatient hospices, and 5 outpatient specialist palliative care teams) were identified for this study. Each institutional leader was contacted and asked to distribute the provided questionnaires to three team members of different professions as a means of stratified sampling (total sample size=168). Financial incentives were not used, and participation was voluntary and encouraged by reminder letters and e-mails to the institutional leaders. Questionnaires could be returned by fax, mail, or e-mail, and those containing personal identifiers were anonymized. The questionnaire included 19 quantitative items and 1 open-ended free-text item asking participants to describe, from their perspective, a typical case of an error in palliative care.

The questionnaire was created by our multiprofessional research group (n=5), and was based on prevalent models from the research literature and expert knowledge about medical errors in palliative care.^8,15 Over three meetings, the questionnaire was discussed, revised, and piloted for wording, layout, length, instructions, and face validity. We added one open-ended free-text item to gain a less standardized and richer description in participants' own wording, and to encourage contextualization of the experience provided.^16–18

Analysis of data

All data provided within the free-text items were transcribed verbatim and listed in a spreadsheet. No specific qualitative data analysis software was used. Analysis of the qualitative data was performed according to qualitative content analysis as introduced by Mayring.¹⁹ This method is based on an open coding process with an inductive definition of categories, a coding process structured by systematic analytical steps. The central step in this qualitative method is the clarification of an abstraction level to which the paraphrased material should be generalized and reduced. The method has been used in palliative care research in the past.^20,21

The analytical process was conducted by a multiprofessional research team consisting of one physician (ID), one nurse (AP), one psychologist (KK), and one theologian (BL). Only the physician and the nurse had previously been scientifically engaged with the general topic of errors in medicine; it was a new field of study for the other two researchers. Initially, all researchers read the free-text answers independently to familiarize themselves with the data. Two researchers (ID, AP) then independently analyzed each free-text answer (minimal coding unit=one word; maximum context unit=independent example of an error), and coded data according to the rules. Codes were subsequently compared, contrasted, and grounded in data, and abstraction to related categories was performed. During the analysis there was an ongoing discussion of emerging themes and categories, and variance of interpretation in the study group was resolved through communicative validation.

Results

Response rate and description of study sample

The questionnaire was returned by 70 respondents (response rate 42%), 46 (66%) of whom had answered the open-ended question about a typical case of an error in palliative care. As the survey was completed anonymously, we do not know how many institutions or how many professionals per institution responded, and it was not possible to follow up with nonresponders. A comparison between the overall sample and those who responded to the open-ended item is shown in Table 2. No significant differences regarding any demographic characteristic (age, sex, profession, professional experience, and work setting) were found in a comparison between the response group and the overall sample (chi-square test, p<0.05).

Table 2.

Demographic Characteristics of the Respondents

	Overall sample (n=70) n (%)^a	Open-ended item sample (n=46) n (%)^a
Age^b
≤30 years	4 (6)	3 (7)
30–39 years	19 (27)	14 (30)
40–49 years	20 (29)	11 (24)
50–59 years	17 (24)	14 (30)
≥60 years	4 (6)	3 (7)
Not indicated	6 (9)	1 (2)
Gender
Female	42 (60)	26 (57)
Male	21 (30)	18 (39)
Not indicated	7 (10)	2 (4)
Profession^c
Nurses	35 (49)	21 (42)
Physicians	20 (28)	17 (34)
Social workers	10 (19)	6 (12)
Spiritual care workers	3 (4)	3 (6)
Psychologists	2 (3)	1 (2)
Others	2 (3)	2 (4)
Professional experience in general
<1 year	0	0
1–5 years	7 (10)	4 (9)
6–10 years	8 (11)	5 (11)
>10 years	53 (76)	36 (78)
Not indicated	2 (3)	1 (2)
Professional experience in PC
<1 year	5 (7)	2 (4)
1–5 years	24 (34)	18 (39)
6–10 years	22 (31)	15 (33)
>10 years	12 (17)	8 (17)
Not indicated	7 (10)	3 (6)
Work setting^c
Inpatient palliative care unit	46 (60)	31 (57)
Inpatient hospice	14 (18)	9 (17)
Outpatient palliative care team	13 (17)	9 (17)
Outpatient hospice service	5 (6)	5 (9)

Percentages may not sum up to 100 due to rounding.

For reasons of anonymity, the question did not ask for the exact age in years, but presented cohorts of ten-year periods.

Multiple answers permitted. Palliative care units and outpatient palliative care teams are led by physicians and focus on medical crisis management, while inpatient hospice and outpatient hospice services are led by nurses and focus on end-of-life care.

Quantitative content analysis

The data in the free-text field varied in terms of length and content, ranging from single key words to rich case descriptions. The answers from eight respondents contained more than one subject or example. Table 3 shows the distribution and frequencies of answer types.

Table 3.

Answer Types and Frequencies

Type of answer	Data distribution by response type (n=45)	Total number of individual coding units within each response type (n=57)	Example quote
Key word	2	9	“Overdosage”
Multiple key words	12	15	“Incorrect titration and conversion of opioids”
Short sentence/vignette	22	24	“Overdosage of opioids caused by fear of the patient's pain is leading to a reduction of vigilance and appearance of adverse drug effects”
Case description	9	9	“Switch from an oral to a regular s.c. application of morphine; home care team does not dare to tell me that this cannot be done during weekends (I could have visited); patient suffers from severe withdrawal symptoms including nightmares”

Qualitative findings

Two main categories emerged during the analytical process, “areas of errors in palliative care” and “causes and explanations of errors.”

Areas of errors in palliative care

The reported errors were assigned to seven different areas of concern in palliative care: medication, sedation, communication, care organization, treatment plan, end-of-life care, and history taking. In terms of medication, most respondents cited errors in the choice or adjustment of drug dosage, for example:

“Wrong charging or programming of syringe divers with pain medication, patient receives too much pain medication and becomes very sleepy.” (#68, nurse)

In addition to medication in general, many professionals specifically mentioned errors in palliative sedation, as the following quote illustrates:

“A patient was agitated, aggressive, denied everything -> sedation of the patient; instead of that an analgetic/anxiolytic therapy should have been started.” (#22, medical specialist)

Four subgroups were identified within the communication errors category: general errors in communication, as well as specific errors in communicating with the patient, with family members, and among team members. The following quotes provide examples:

“Communication in the terminal phase, e.g., ‘It will get better somehow.’ (#56, nurse)

“Problems in communication between physician and patient, when the patient is holding unrealistic ideas but you don't want to disappoint him.” (#18, intern)

Table 4 illustrates the seven categories for types of identified errors, with corresponding subcategories and the total number of coding units assigned to each category.

Table 4.

Categories for Types of Errors

Areas of errors	Subcategories	Number of coding units and distribution of professions
Medication	• Wrong administration	20 (9 P, 10 N, 1 PY)
	• Wrong dosage or adaption of dosage
	• Fear/prejudice concerning pain medication; hesitant use of analgetics
	• Wrong application
	• Ignorance of adverse drug reaction
	• Reduction of autonomy of the patient caused by drug therapy
	• Wrong handling of syringe drivers
Palliative sedation	• Sedation without indication	3 (2 P, 1 SW)
	• Sedation too rapid
	• Sedation too deep
Communication		19 (7 P, 4 SW, 6 N, 1 SC, 1 PY)
General	• Too little/unclear information
	• No concordant communication of the treatment strategy
Patient	• Too late information anticipates that the patient can arrange things
	• Inadequate symptom control in unconscious patients
	• To hold or to create unrealistic hopes
Family	• Lack of information/integration of the family
	• Getting too late in contact with the family (e.g., in case of impairment)
Team	• Lack of communication of medical directives
	• Unclear documentation (medication/prescription)
	• Loss of information because of a large team
Organization or system	• No availability in emergency crises	7 (1 P, 3 N, 3 SW)
	• Missed opportunity for transferring the patient home
Treatment plan	• No or no clear treatment plan or goal	6 (3 P, 1 N, 1 SC, 1 PY)
	• Point of time of treatment plan changes
	• Restriction on physical symptoms (no holistic approach)
	• No differentiation between own will and patient's will
End-of-life care	• “Overtreatment”/“overcare” / “overdiagnostics”	5 (1 P, 3 N, 1 “others”)
	• Artificial nutrition and hydration in the dying process
	• Antibiotics in the terminal phase
Medical history	• Unclear/insufficient medical history	3 (2 P, 1 N)
	• Wrong evaluation of symptoms

N, nurse; P, physician; PY, psychologist; SC, spiritual care provider; SW, social worker.

Causes and explanations of errors in palliative care

Six categories of perceived causes for errors were evident in the descriptions provided by the respondents, and include miscommunication, system failure, dysfunctional attitudes, lack of knowledge, wrong use of technology, and misjudging. The most frequently mentioned category was miscommunication with the patient or family:

“Because of a too late communication with the patient and/or his family, the patient is not able anymore to talk to his family or to care about important issues.” (#21, nurse)

Table 5 illustrates the six categories for perceived causes of errors, and the total number of coding units in each category.

Table 5.

Categories for Causes of Errors

Causes		Number of coding units and distribution of professions
Miscommunication	• Lack of communication with the patient or the family	16 (6 P, 4 N, 2 SC, 4 SW)
	• Fear of communication
	• Failure to disseminate information to all persons involved
System failure	• Hierarchical structures	13 (3 P, 3 N, 7 SW)
	• Too many members on a team
	• Dysfunctional shift work
	• Unclear competencies
	• Workload too high, lack of time
	• Confusing management of patient charts
Attitudes	• Fear of overdosing drugs	5 (3P, 2N)
	• Fear of patient's pain
	• Lacking distance from the patient
	• Lacking willingness to take responsibility
Lack of knowledge	• Lack of skills	8 (2 P, 4 N, 1 SW, 1 “other”)
	• Lack of knowledge (especially in pain treatment)
Technology	• Too much technical equipment	5 (1P, 4N)
	• Wrong handling of syringe divers
Misjudgement	• Misjudgement of symptoms	16 (6 P, 8 N, 1 PY, 1 SW)
	• Misjudgement of family members
	• Misjudgement of the prognosis

N, nurse; P, physician; PY, psychologist; SC, spiritual care provider; SW, social worker.

Discussion

We conducted a cross-sectional survey to better understand what palliative care professionals perceived as a typical error in palliative care, and how they describe the situation. Our data indicate that medical errors in palliative care, as seen by those who work in the field, primarily affect the areas of medication and communication, and that miscommunication and system failures are perceived as the leading causes for errors in that medical discipline.

Medication errors are known to be one of the primary areas of errors in medical fields other than palliative care. Errors in drug prescription and administration are the most frequent types of medical mistakes, both in ambulatory and hospital care.^22–24 It seems logical that palliative care, with its emphasis on symptom control and polypharmacy, is particularly prone to medication errors.^25,26 Other disciplines may provide guidance regarding effective prevention of these errors in the future.

In our study, communication was identified as an area of importance in terms of errors in palliative care. While it is accepted that miscommunication within the health care team may be a primary cause of medical errors,^27–29 there is a scarcity of literature to date suggesting that communication may also be an independent area of errors, i.e., that an error could also occur in communication with the patient or family members, resulting in a directly harmful result.

In palliative care, communication is the mainstay of care, and communicative competencies are extremely important for the effectiveness and success of palliative treatment.^30–32 In contrast to symptom control, communication is an area in which it seems to be more difficult to generate evidence about what constitutes a standard of care, thus it is more difficult to deliniate what constitutes a communicative error.³³

That communication is an important cause for errors in palliative care can be well understood, particularly as interdisciplinary and multidisciplinary teamwork is regarded as an essential and effective component of the holistic approach and concept of palliative care.^34,35 However, such approaches to enhancing personal communication skills and teamwork are only beginning to be implemented in a systematic fashion, and more emphasis needs to be placed on these aspects in training programs.³⁶ As well, more research data is needed to understand how improved interprofessional communication influences outcomes in palliative care.

In addition to determining the types and causes of errors in palliative care, our study further revealed minor categories with considerable relevance for a discipline dealing with terminally ill patients and end-of life care.

Palliative sedation may be acknowledged as a subcategory of medication errors; however, in consideration of its legal and ethical implications at the end of life, we decided to define it as a distinct field of error. Palliative sedation is a highly controversial form of treatment among palliative care professionals, and published clinical guidelines are rather vague concerning the indication for sedation as well as the depth and duration of it.³⁷ Moreover, palliative sedation is fraught with ethical controversies, making it more difficult to formulate a standard of care in this area. What can be seen as an error in Germany may also be considered completely differently in another legal or cultural background. In the future it will be important to take a very careful and culturally sensible approach towards the definition of errors in terms of therapeutic sedation in palliative care.

Discussing the treatment plan or goals of care (advance care planning) is an important issue in palliative care,^38,39 and a lack of discussion may be perceived as an error. In our study we have seen that errors may occur by delaying treatment planning discussions, thereby neglecting to set clear and coherent treatment goals and possibly disrespecting the patient's autonomy. Two types of errors can be distinguished in this context: (1) noncommunication of advance care planning with the patient and family members and (2) lack of team communication about goals of care. The former can prevent shared decision making and hinder the patient's ability to define personal goals of care as a means of autonomic decision making. The latter refers to situations in which neglecting to communicate goals of care among team members may result in professional activity that is not shared with other team members, sometimes leading to “overcare” (“personal hygiene at any cost”), “overtreatment” (“much radiotherapy because medical director is radiotherapist,” “antibiotics in terminal phase”), and “overdiagnosing” (“too much neurological diagnostics without consequence”).

In his studies on the management of human errors in medicine, Reason et al. demonstrated that a systematic approach to medical errors is more important and more continuative than a personal approach for detection and prevention of errors.⁴⁰ Respecting the multiplicity of professions, disciplines, interfaces, and services in palliative care, the discipline is prone to errors of system and organization, and hence should focus on that systematic view for the detection and prevention of errors.

Oser described three distinct factors that contribute to an open and constructive culture regarding errors and handling of errors in an institution: (1) dominating values and norms; (2) specific competences (emotional, social, and methodological); and (3) awaiting instruments for the handling of errors.⁴¹ With respect to the first two factors, we can presume that palliative care is well prepared, but instruments for the handling of errors are rare. As we tried to identify important areas and causes of errors in palliative care, our study can be regarded as an initial step towards the last factor. In the future these limited findings must be further substantiated with more data including the perspective of patients and families.

Limitations

As the sample of the present study was restricted to the Bavarian region of Germany, we do not claim to provide a comprehensive or completely transferable picture of attitudes of professionals regarding errors in palliative care. Generalizing from qualitative data needs to be treated with caution, and we acknowledge that our data reflects only the experiences and descriptions of the participants involved and did not consider the view of patients or family. Consequently, to acquire more generalizable data, a broader sample, including professionals from different cultural, legal, and ethnic backgrounds, should be analyzed. As the presented data were obtained in the context of a quantitative survey, respondents' qualitative data may have been influenced by the preceding quantitative questions. Moreover, there may be a selection bias, as directors chose staff members to complete the survey.

However, as no comparable data has been published on this topic to date, the data from the present study offers an initial overview of aspects that could be important in terms of errors in palliative care. Further research is now needed to generate more detailed data for different causes and areas, and should involve more representative samples, including the view of patients and their families.

Footnotes

Acknowledgments

We thank our team colleagues at the Interdisciplinary Center for Palliative Care in Munich for their help in the development of the questionnaire. A special thank-you goes to Katja Kühlmayer and Benno Littger for their support with the qualitative analysis. Moreover we are very grateful for the support of the German Society of Palliative Medicine.

Author Disclosure Statement

The authors state that no competing financial interests exist.

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