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Contents lists available at ScienceDirect

Collegian
journal homepage: www.elsevier.com/locate/coll

Medication safety challenges in the palliative care setting:

Nurses’ perspectives
Hanan Khalil a,∗ , Peter Poon b , Anny Byrne c , Eli Ristevski a
a
Monash Rural Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
b
Monash University, Faculty of Medicine, Nursing and Health Sciences, Victoria, Australia
c
Gippsland Region Palliative Care Consortium, Victoria, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Aim: To explore medication safety issues faced by general and palliative care community nurses working
Received 26 October 2018 in rural and remote palliative care domiciliary settings.
Received in revised form 3 April 2019 Method: An online survey for nurses working in rural communities was conducted across the South East
Accepted 4 April 2019
region of rural Victoria, Australia. Nurses from 18 community based health care organisations across the
Available online xxx
region were invited to participate in an anonymous survey addressing medication safety issues in the
palliative care settings. Qualitative data obtained from the open-ended survey questions were analysed
Keywords:
inductively.
Medication safety
Palliative care
Results: A total of 29 nurses completed the survey (response rate 28% from potential respondents). Most
Nurses of the nurses were working in a rural practice providing a mixed model of community palliative care
Cytotoxic and community nursing. Medication safety issues raised by the nurses included; errors associated with
Dose administration aids dose administration aids, frequency of medications reviews undertaken by clinical pharmacists of clients’
medications, high occurrence of medications error reporting, lack of awareness of medications initiated
by nurses and cytotoxic medications handling.
Conclusion: Targeted interventions addressing the identified issues raised by community general and
palliative care nurses have the potential to improve medication safety in the domiciliary palliative care
setting.
© 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Summary of Relevance • Medication safety issues raised by the nurses included;

The Problem
Little is known about medication safety issues in the community
palliative care settings in rural and remote areas.
What is already known about this topic
• Primary care settings have challenges due to the fragmentation
of services in the community and a lack of co-ordination and
communication between primary care providers
• To date, only a few studies have addressed the challenges that
general and palliative care community nurses face, and in par-
ticular, anticipatory medications in the community palliative
care setting where access to medications and care are crucial to
patients’ quality of life and end-of-life care.
 errors associated with dose administration aids (DAA),
 Frequency of medications reviews undertaken by clinical
pharmacists of clients’ medications,
 high occurrence of medications error reporting, and cytotoxic
medications handling
Targeted interventions such as regular medications reviews
undertaken by pharmacists and medication safety education to
nurses have the potential to improve medication safety in the pal-
liative care setting.
;1;
1. Introduction

What this paper adds Provision of palliative care in primary care settings is challeng-
ing due to fragmentation of services in the community and lack of
co-ordination and communication between primary care providers
∗ Corresponding author. (Clarke, Bourn, Skoufalos, Beck, & Castillo, 2017). These challenges
E-mail address: hanan.khalil@monash.edu (H. Khalil). create gaps where patients’ safety may be compromised. Patients

https://doi.org/10.1016/j.colegn.2019.04.001
1322-7696/© 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Please cite this article in press as: Khalil, H., et al. Medication safety challenges in the palliative care setting: Nurses’ perspectives.
Collegian (2019), https://doi.org/10.1016/j.colegn.2019.04.001
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Table 1
Survey questions.

Demographics
1 Please state your current qualification
2 In what year did you graduate
3 How many years have you worked in community nursing? (Graduate nurses = 0 years)
4 Which Local Government Area do you work in?
5 What is your current work environment? (choose only one)
䊐 Combined Community Palliative Care and District Nursing Service
䊐 Dedicated Community Palliative Care Service
䊐 Dedicated Community District Nursing Service
Dosage Medication Administration Aids (DAA’s)
Refers to a device or packaging system for organising doses of medicines according to the time of the administration (i.e. Webster Pack).
1 Does your service administer oral medication directly from its original packaging OR utilize DAA’s?
䊐 Original Packaging
䊐 DAA’s
2 In your experience, when has using a DAA become an issue for yourself or the client?
䊐 No DAA available in the house to administer medication at appropriate time
䊐 Client unable to utllize DAA independently
䊐 Confusion with day sequence/labelling for administration on the DAA
䊐 Incorrectly packed
䊐 Client commences a new medication
䊐 Client commences short course medication
䊐 All of the above
Medication review
1 How often do you think a medication review should be conducted by a pharmacist for clients receiving nursing assistance for medication compliance in
the community?
䊐 Never
䊐 3 Monthly
䊐 6 Monthly
䊐 12 Monthly
䊐 Only if clinically indicated - i.e. a change to medication
Medications handling
1 Have you experienced any medication incidents around medication storage?
䊐 Yes
䊐 No
2 Have you been involved in or been made aware of any incidents relating to medication disposal?
䊐 Yes
䊐 No
3 Have you been involved in or been made aware of any incidents around nurse initiated medications?
䊐 Yes
䊐 No
䊐 If Yes, can you outline the details of the incident?
4 Are you aware of the medications that a nurse can ’nurse initiate’ in your organization?
䊐 Yes
䊐 No
䊐 Please list,
Cytotoxic preparations
1 Does your service handle cytotoxic preparations?
䊐 Yes
䊐 No
2 Have you been involved in or been made aware of any incidents in relation to cytotoxic medications (i.e. storage, administration, and handling)?
䊐 Yes, please explain
䊐 No
3 Have you had formal education on how to handle, store or administer these medications?
䊐 Yes
䊐 No
Training
1 Has your nursing qualification provided you with adequate theoretical understanding in all aspects of medication management in a palliative community
nursing setting?
䊐 Yes
䊐 No
䊐 If not, please outline where you believe nursing courses could improve practical/theoretical training in the area of community-based medication
management.
Access
1 Have you encountered any medication incidents where access to medications was the underpinning element of the incident?
䊐 Yes
䊐 No
䊐 If YES, please describe what happened.

rely on general and palliative care community nurses to ensure
the co-ordination of these services (Danielsen, Sand, Rosland, &
Førland, 2018; Khalil, Bell, Chambers, Sheikh, & Avery, 2017; Khalil,
Parr, & Waller, 2017; Khalil, Shahid, & Roughead, 2017) A recent
systematic review of palliative care research in rural and remote
settings has identified many strategies to improve palliative care
delivery (Bakitas et al., 2015. Strategies suggested included; pro-
viding expert care to seriously ill patients, community support,
academic support and partnerships, telehealth, community advis-
ers, and other creative paradigms. Furthermore, the authors found
by enhancing education within the rural community setting, pri-

Please cite this article in press as: Khalil, H., et al. Medication safety challenges in the palliative care setting: Nurses’ perspectives.
Collegian (2019), https://doi.org/10.1016/j.colegn.2019.04.001
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mary care clinicians may have the knowledge to integrate 24-hour Table 2
Medication safety issues (N = 29).
palliative care access to all patients with life-threatening illnesses.
Integration of palliative care across primary care settings is Parameters identified by nurses surveyed* N %
crucial to ensure the continuity of care and improve patients’ out- Dose Administration Aids (DAA)
comes at the end of life. This requires palliative care providers to Use of Dose Administration Aids 21 72
be knowledgeable regarding the patient’s illness, prognosis, treat- Issues when using DAAs
ment options, risks, benefits and achievable outcomes. Several Confusion with sequence of days/labelling of DAA 6 21
Client commencing new medications 5 19
factors were identified in facilitating integrated care. These fac-
Incorrect packaging 4 16
tors include: the presence of leadership from senior management, Client unable to use DAA independently 3 15
the presence of a supportive organizational culture, and availability Client commencing sort medications 2 15
of information technology that facilitates data sharing, communi- No DAA available in house 2 10
Frequency of medications reviews by pharmacists
cation across healthcare teams, and resources such as budgeting
Should be reviewed 3-6 month 18 62
and adequate staffing and education (Brazil, 2017). The commu- Should be reviewed yearly 6 21
nity nurse’s role, in collaboration with the general practitioner Medication handling
and other health professionals, is crucial to improve the indepen- Incidents around medication storage 9 31
dence and health outcomes of individuals living in the community. Incidents relating to medication disposal 5 17
Incidents around nurse initiated medications? 2 7
Their multifaceted roles include managing patients’ medications,
Awareness of medications that a nurse can ’nurse initiate’ 24 82
assessing clinical and personal care needs and care co-ordination. in your organization
Their roles in rural and remote settings are particularly challenging Cytotoxic preparations
due to the distance nurses travel to reach their patients, often- Handling of cytotoxic preparations 24 82
Incidents in relation to cytotoxic medications (i.e. storage, 12 41
limited resources, inadequate specialist medical support, and lack
administration, and handling)?
of access to medications and other services (Khalil & Lee, 2018; Tan, Formal education on how to handle, store or administer 21 72
Emmerton, Hattingh, & La Caze, 2015). these medications?
Anticipatory prescribing can be defined as the proactive pre- Training
scribing of medicines that are commonly required to control Qualifications adequate for all aspects of medication 11 52
management in a palliative community nursing setting?
symptoms in the last days of life (Faull, Windridge, Ockleford, &
(n = 21)
Hudson, 2013). Often they are administered subcutaneously. Antic- Access
ipatory medications are used at the end of life to ease patients’ pain Incidents where access to medications was the 8 27
and improve their quality of life. Reasons for their use include: underpinning element of the incident?
worsening of existing symptoms, decrease in oral absorption of *
The numbers shown in the table refer to the number of nurses who answered
medications, inability of patients to swallow and anticipation for positively to the questions.
end-of-life symptoms and patient distress. Access to these medica-
tions for palliative care patients is crucial to provide timely care of Table 3
pain relief and symptoms relief (Payne et al., 2014). Qualitative analysis.
To date, only a few studies have addressed the challenges that 1 Medications storage/disposal issues experienced by nurses
primary and community palliative care nurses face, particularly in • Storage
regard to anticipatory medications in the palliative care setting, • Disposal
• Lack of knowledge of Nurse initiated medications
where access to medications and care are crucial to patients’ quality
• Medications incidents associated with storage/disposal
of life and end-of-life care in rural and remote settings (Khalil, Bell 2 Medications incidents reporting
et al., 2017; Khalil, Parr et al., 2017; Khalil, Shahid et al., 2017). This • No stock
short report focuses on exploring medication safety issues faced • No anticipatory medications
by general and palliative care community nurses working in rural • No valid scripts
• Dose Administration Aids have not been packed and collected
palliative care settings.
• Driving for long distances to get medications

2. Methods 2.2. Subjects

2.1. Study design
An online survey was distributed to community nurses work-
ing in rural and remote communities across the South East region
of Victoria, Australia. A full description of the study methodol-
ogy was published in Khalil, Poon, Byrne and Ristevski (2019). In
summary, an anonymous online survey was emailed to general
and palliative care nurses working in community palliative care
in the Gippsland region in south-eastern Victoria, Australia. The
survey link was emailed to managers in 18 health care organiza-
tions, who forwarded the survey to eligible staff. Emails reminders
were sent to all staff to increase the response rate to the survey.
All study procedures were approved by Monash University Human
Research Ethics Committee (2017-5808-15049). A summary of the
survey questions reported on in this paper is shown in Table 1. Data
was analysed using descriptive analysis. The qualitative data was
grouped together and free text comments were inductively themed
and coded by the authors. Topics presented arose in the sample as
a whole as shown in Tables 2 and 3.
Nurses from 18 community health care organisations across
the region were invited to participate in an anonymous survey
addressing medication safety issues in the palliative care setting.
One primary health care organisation declined to participate in the
study as it did not support palliative patients. Quantitative data
was reported elsewhere (Khalil & Lee, 2018). For the purpose of this
study, community nurses (enrolled, registered, bachelor or diploma
qualified) were nurses who worked in care home environments and
employed by community health services and/or aged care facilities.
These nurses focus on providing advice and support to patients and
carers in the management of palliative care symptoms. They often
liaise with other health care practitioners to support overall care of
patients.
3. Results
A total of 35 nurses responded to the invitation, and 29 com-
pleted the survey (response rate 28%). Most nurses were working
in practice settings providing a mixed model of community pallia-

Please cite this article in press as: Khalil, H., et al. Medication safety challenges in the palliative care setting: Nurses’ perspectives.
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tive and general community nursing (n = 23, 79%). Approximately
one third of nurses (n = 9, 31%) were working in remote settings
and the remainder were located in regional areas.
Medication safety issues raised by the nurses included: errors
associated with dose administration aids (DAA), frequency of
medication reviews undertaken by clinical pharmacists of clients’
medications, high occurrence of medication errors reporting, lack
of awareness of medications initiated by nurses, and lack of
knowledge and training regarding cytotoxic medications handling.
(shown in Table 2).
4. Discussion
The study identified several barriers facing medication safety in
rural and remote areas in the primary care setting. Nurses work-
ing in primary care settings in rural and remote areas face various
challenges regarding access and supply of medications, distance to
travel to attend to patients and upskilling and education to provide
best practice medication management to patients in the home. A
major challenge raised by palliative care nurses was safety issues
associated with DAA. DAA are used very frequently by the elderly
and vulnerable populations, who are taking multiple medications.
However, their use must be based on knowing the barriers associ-
ated with them and addressing these through active collaboration
between the general practitioner, pharmacist and client or carer.
The UK National Institute for Health and Clinical Excellence review
of dosing aids concluded that there was lack of strong evidence
to support their widespread use and they should only be used
to overcome practical problems if there is a specific need (Elliott,
2014). These results are consistent with issues raised by community
nurses (Khalil & Lee, 2018). Safety issues include: client confusion
with sequence of days/labelling of DAA, client commencing new
medications, incorrect packaging, client unable to use DAA inde-
pendently and unavailability of DAA in patients house at the time
of visit by general or palliative care community nurses. While the
evidence suggests DAAs are beneficial for clients on multiple med-
ications, our study found they are associated with client confusion.
A Home Medicines Review, which includes an assessment by
a pharmacist of all the medicines taken by a patient, can help to
identify causes of medication errors or non-adherence, and assess
the patient’s suitability for a DDA or other strategies to improve
medication management (Elliott, 2014). The nurses surveyed in our
study reported medication reviews should be undertaken regularly,
three to six monthly, by a pharmacist. Several reviews investi-
gating the efficacy of medications reviews on patients’ related
outcomes have shown that they improve medication optimisation
(Akinbosoye, Taitel, Grana, Hill, & Wade, 2016). Interventions that
included medication review had a significant impact on patient out-
comes by reducing mortality, emergency visits and hospitalization
(Khalil, Bell et al., 2017, Khalil, Parr et al., 2017; Khalil, Shahid et al.,
2017; Ryan et al., 2014).
Problems with storage and disposal were also identified by the
nurses in this study. This finding is significant for medications with
misuse potential including opioids that maybe easily ingested by
children or misused by other family members (Spitz et al., 2011).
Lack of stock and the absence of a valid script were other issues cited
by 25% of the respondents. This is a significant problem in rural and
remote areas where access to medications may be hampered by
logistics with direct impact on patients.
Lack of knowledge of which medications can be initiated by
nurses was another issue raised by 18% of the surveyed nurses. A
study by Cabilan, Eley, Hughes, and Sinnott, (2016) found that there
was an overall deficit in nurses’ knowledge of medications and their
mechanism of actions. They also stated that nurses usually initi-
ated medications based on clients’ needs. Community nurses may
initiate discussions about anticipatory medications to help con-
Please cite this article in press as: Khalil, H., et al. Medication safety challenges in the palliative care setting: Nurses’ perspectives.
Collegian (2019), https://doi.org/10.1016/j.colegn.2019.04.001
trol symptoms in those who are dying. A recent qualitative study
by Bowers and Redsell (2017) examined community nurses’ deci-
sions making regarding initiating anticipatory medication at end of
life and found that they perceived that part of their role for dying
patients was to advocate for the dying person and their families’
needs, as well as initiate discussions with families about anticipa-
tory medicines.
Only half of the respondents cited that their training and nursing
qualifications provided them with adequate theoretical under-
standing in all aspects of medication management in a palliative
community nursing setting. When asked about examples of courses
that would help them to upskill, they were non-specific in their
responses but focussed on ongoing education and having access
to regular refresher courses. Targeted regular educational inter-
ventions for nurses working in the community in the palliative
care setting have the potential to improve nurses’ knowledge on
many aspects of medications safety. A recent systematic review by
Härkänen, Voutilainen, Turunen, and Vehviläinen-Julkunen, (2016)
found that educational interventions generally had a positive effect
on nurses’ knowledge; however, blended courses had the most
positive results compared to online courses.
Cytotoxic handling risks were significant for staff, clients and
carers in the community given the lack of training indicated by a
quarter of the survey respondents and more than a third of respon-
dents involved in cytotoxic handling incidents. A study by Tan et al.
(2015) identified an important role of pharmacists providing out-
reach roles in rural and remote areas, especially in the areas of
cytotoxic management, education and training (Tan et al., 2015).
These models have the potential to decrease risks of cytotoxics and
improve safety training for community nurses (Tan, Emmerton, &
Hattingh, 2012).
Our study has several limitations. Primarily, the low response
rate and small number of respondents included in the study. Sec-
ondly, this study provides insights into a small sample of nurses
in one geographical in regional Australia and may not be reflective
of community nurses working in other areas or specialities. More-
over, clients and carers were not surveyed to determine the impact
of these challenges on them.
In conclusion, several challenges were identified by general and
palliative care community nurses working in rural and remote areas
in this study. The most significant were the errors associated with
dose administration aids, the frequency of medications reviews
undertaken by pharmacists, lack of knowledge regarding nurse ini-
tiated medications and cytotoxic handling. Further research into
clients’ and carers’ views of medication safety issues could identify
targeted interventions to improve medication safety in the pallia-
tive care setting..
Ethical approval
This study received Ethics approval from Monash Human Ethics
Committee (CF14/3987 - 2014002063).
Funding
This study received no funding.
Authors’ disclosure of interest
The authors have no conflict of interest.
Acknowledgement
The authors would like to thank all the participants who took
part in the survey.
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