Date of Award


Degree Name

Doctor of Philosophy (College of Nursing)

Schools and Centres

Nursing and Midwifery

First Supervisor

Professor Jane Phillips

Second Supervisor

Professor Tim Shaw


Background: Opioids are a high-risk medicine, and one of the most frequently reported drug classes causing patient harm. In specialist palliative care inpatient services opioids are widely used to manage cancer pain and other symptoms. Palliative care inpatients are vulnerable to both exposure to, and harm from, opioid errors due to a combination of their: advanced age, comorbidities which affect drug metabolism, polypharmacy, and the seriousness of their illness. Despite this potential for harm, and the frequency of opioid administration in this specialist setting, little is known about opioid errors in palliative care. Better understanding the prevalence, patient impact and error contributing factors in the specialist palliative care inpatient setting will help to strengthen and support safe opioid delivery and minimise opioid error harms for this vulnerable population.

Aim: The PERISCOPE project aims to identify the: i) burden and characteristics of opioid errors; and ii) actions required to support safe opioid delivery within specialist inpatient palliative care services.

Methods: Research design: The PERISCOPE research project is a two-phase, pragmatic, explanatory sequential mixed methods study. This doctoral research project is situated within a quality and safety agenda and guided by a multi-incident analysis framework, and the Yorkshire Contributory Factors Framework. The PERISCOPE Project employed five discreet but inter-related studies conducted over two-phases. During Phase one, a: systematic literature review of opioid errors in palliative care services (Study 1); two retrospective reviews of clinical incidents involving opioids in palliative care services, one at a jurisdictional level (Study 2) and the other within three local specialist palliative care inpatient services in New South Wales (NSW) (Study 3) was undertaken. A review of opioid error contributing factors documented in clinical incident reports in local specialist palliative care inpatient services was also completed (Study 4). Phase two involved a series of semi-structured interviews and focus groups which sought palliative care clinicians’ and service managers perceptions of opioid errors in their specialist palliative care inpatient services (Study 5). Data integration and meta-inference of these data were undertaken following the completion of the two study phases, and facilitated a series of individual and systems-level recommendations to strengthen safe opioid delivery in specialist palliative care inpatient services.


Phase one: The systematic review revealed a paucity of empirical data, with the reported opioid errors limited to deviations from opioid prescribing, and no opioid administration errors in the palliative care clinical setting reported. These systematic review findings contrasted with the results of the NSW state-wide and local retrospective reviews, which found that opioid administration errors accounted for three-quarters of reported opioid related incidents. The majority of these opioid errors were due to omitted dose errors. While serious patient harm due to error was exceedingly rare in palliative care services, half of all palliative inpatients exposed to an opioid error experienced iatrogenic harms. Over half of these errors resulted in opioid under-dose for the patient, which adversely impacted on their pain management. Active failures (i.e., errors made by the palliative care clinician) were reported as contributing to two-thirds of these opioid errors, and one-fifth of errors were directly attributed to deficits in clinical communication.

Phase two: The qualitative study with palliative care clinicians confirmed these results and identified additional error contributory factors including: the complexity and frequency of opioid delivery in specialist palliative care inpatient services, sub-optimal skill mix, and the absence of a clinical pharmacist in the palliative care service. This study also highlighted that palliative care services’ had substantially invested in creating and sustaining a positive safety culture, which drove the services’ approach to error mitigation strategies. Meta-inference of the integrated data across the five studies revealed four factors that are required to support safe opioid delivery in specialist palliative care inpatient services: i) embedding a positive opioid safety culture; ii) enabling optimal skill mix, staffing and resources; iii) privileging opioid education in the palliative care service; and iv) empowering clinicians to identify, challenge and report opioid errors.

Conclusion: Despite specialist palliative care inpatient services clinicians ordering and administering opioids in high frequency, the overall prevalence of opioid errors in this setting is low. However, the most prevalent opioid errors that were identified were omitted dose errors, which caused unnecessary pain and suffering for affected palliative care inpatients. These errors were largely due to human error as a result of high workload and sub-optimal skill mix, and the use of paper-based versus electronic medication management systems.

The PERISCOPE Project confirmed that the opioid error contributory and mitigating factors in specialist palliative care inpatient services are multifactorial, encompassing individual and systems factors. Accordingly, any strategies to reduce opioid errors must apply an integrated systems approach in order to be of impact. Pro-actively embedding and sustaining a culture of opioid safety is a core component of supporting safe opioid delivery and reducing opioid errors in specialist palliative care inpatient services. While the PERISCOPE Project identified an overarching positive safety culture which encouraged and supported error reporting and facilitated organisational learnings to minimise and prevent opioid errors, there are still opportunities to reduce the prevalence of opioid errors, particularly missed doses in this setting. These strategies include ensuring optimal skill mix and medical/nursing ratios each shift, prioritising the transition from paper-based to electronic medication management systems, and mandating a minimum ratio of palliative care pharmacist hours for all specialist palliative care inpatient services.

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