Background: Opioids are high risk medicines and are frequently implicated in medication errors causing patient harm. In oncology and palliative care services, opioids are the primary pharmacological treatment for cancer pain and are routinely used to manage pain and other symptoms at the end of life. Despite their widespread use, little is known about the incidence and impact of opioid medication errors in adult oncology and palliative care settings.

Aim: To identify the incidence, types and patient impact of opioid medication errors in adult palliative care and oncology settings reported in the peer reviewed literature.

Methods: This systematic review sought empirical studies published between 1980 and 2014, in English, reporting data on opioid medication error incidence, types or patient impact, in adult palliative care and/or oncology services.

Results: Five studies met the inclusion criteria, reporting patient data from the clinical setting (n=3), the home care setting (n=1) and palliative care clinicians’ perceptions of opioid errors (n=1). Opioid error incidence was difficult to determine as each study focused on a single narrow area of error. Deviations from opioid prescribing guidelines were reported in 81% of patients, making this the predominant opioid error type. No studies reporting opioid administration errors in the clinical setting were identified. Notably, patient harm resulting from opioid errors was not reported in any of the included studies.

Conclusions: This review highlighted that opioid error incidence reporting, identification of error types, and patient impact of opioid errors in oncology and palliative care settings are under-explored areas of patient safety. Defining, identifying and quantifying error reporting practices in these settings will benefit future quality and safety initiatives.