Clinicians’ perceptions of opioid error–contributing factors in inpatient palliative care services: A qualitative study

Nicole Heneka, Priyanka Bhattarai, Tim Shaw, Debra Rowett, Samuel Lapkin, Jane L. Phillips

Research output: Contribution to journalArticlepeer-review

5 Citations (Scopus)


Background: Opioid errors are a leading cause of patient harm and adversely impact palliative care inpatients’ pain and symptom management. Yet, the factors contributing to opioid errors in palliative care are poorly understood. Identifying and better understanding the individual and system factors contributing to these errors is required to inform targeted strategies. Objectives: To explore palliative care clinicians’ perceptions of the factors contributing to opioid errors in Australian inpatient palliative care services. Design: A qualitative study using focus groups or semi-structured interviews. Settings: Three specialist palliative care inpatient services in New South Wales, Australia. Participants: Inpatient palliative care clinicians who are involved with, and/or have oversight of, the services’ opioid delivery or quality and safety processes. Methods: Deductive thematic content analysis of the qualitative data. The Yorkshire Contributory Factors Framework was applied to identify error-contributing factors. Findings: A total of 58 clinicians participated in eight focus groups and 20 semi-structured interviews. Nine key error contributory factor domains were identified, including: active failures; task characteristics of opioid preparation; clinician inexperience; sub-optimal skill mix; gaps in support from central functions; the drug preparation environment; and sub-optimal clinical communication. Conclusion: This study identified multiple system-level factors contributing to opioid errors in inpatient palliative care services. Any quality and safety initiatives targeting safe opioid delivery in specialist palliative care services needs to consider the full range of contributing factors, from individual to systems/latent factors, which promote error-causing conditions.

Original languageEnglish
Pages (from-to)430-444
Number of pages15
JournalPalliative Medicine
Issue number4
Publication statusPublished - Mar 2019
Externally publishedYes


  • Analgesics
  • hospice and palliative care nursing
  • hospital
  • incident reporting
  • medication errors
  • medication systems
  • opioid
  • palliative care
  • palliative medicine
  • patient safety
  • qualitative research
  • risk management


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