Table 2.

Number (%) of continuous subcutaneous infusion incidents by reclassified severity of harm (n = 1317).

Severity of harm	Description	Example individual incident description	Number of incidents	Percentage of total incidents (rounded to nearest 0.5)
No harm	Patient outcome is not symptomatic, or no symptoms detected and no treatment is required	. . .visited to set the driver up and Metoclopramide not available. . .Stat dose given. . .family struggled to get medication. . . still awaiting GP to prescribe/get hold of alternative. . .managed patients comfort by giving stat doses. . .resolved following day by OOH GP [out of hours general practitioner] who changed prescription for syringe driver [CSCI] so all required medications were readily available. . . – unknown reporter role	273	21
No harm due to mitigating action	Patient outcome is not symptomatic or no symptoms detected and no treatment is required due to an intervention	. . .prescription. . .written. . .prescribed hyoscine hydrobromide 60mg over 24 hours [via a CSCI] when they had intended to prescribe hyoscine butylbromide 60mg over 24 hours. . .nurse realised. . .mistake and put hyoscine butylbromide in the syringe driver. . .doctor noted their mistake within two hours and confirmed. . .hyoscine hydrobromide was never administered – unknown reporter role	81	6
Low harm	Patient outcome is symptomatic, symptoms are mild, loss of function or harm is minimal or intermediate but short term, and no or minimal intervention (e.g extra observation, investigation, review or minor treatment is required)	Patient unsettled. . .doctor could not be called, only one doctor for whole hospital. . . . Agency nurse not familiar with syringe pump [CSCI pump]. . . Nurses did not know how to lock syringe box. Had to wait >3 hours for drug to be prescribed for syringe pump. . . no oxycodone on the ward. . . had to be borrowed from another ward. Wife upset. . .no compassion shown. – unknown reporter role	656	50
Moderate harm	Patient outcome is symptomatic, requiring intervention (e.g. additional operative procedure or additional therapeutic treatment), an increased length of stay or causing permanent or long-term harm or loss of function	. . .visit patient to administer stat doses. . .agitated and pain. . .only ampoule of Oxycodone had been opened and re-taped . . .patient extremely agitated and complaining of pain. . .patient had Oxycodone in the driver [CSCI pump] with 2.5mg Midazolam but sticker attached stated Diamorphine and Midazolam. . .No Diamorphine written up and no Diamorphine ampoules in home. . .administer from opened used ampoule which is against policy . . .GP to visit urgently and administer stat doses but patient died before GP could visit. . . – unknown reporter role	218	16.5
Severe harm	Patient outcome is symptomatic, requiring life-saving intervention or major surgical/ medical intervention, shortening life expectancy or causing major permanent or long-term harm or loss of function	patient discharged. . . no time intervals, no diamorphine or syringe driver [CSCI] issued/prescribed. Midazolam sent out unsuitable for stat use. Not temp[orarily] registered with GP. . . Dr refused visit, ref[erral] to prescribe driver or diamorphine . . .drugs and directive not obtained. . .gave max doses of drugs as prescribed/advice. Went to surgery to get max doses changed/prescribed. Consultant took 30 mins to return phone call to GP and would not prescribe from conversation. . .returned to house 45 minutes later. . . patient had died 10 minutes earlier – unknown reporter role	42	3
Death	On balance of probabilities, death was caused or brought forward in the short term by the incident	Nurse read medication chart. . . identified drug within dispensing box. . .chart states 0.1mg to 0.2 mg and box range states 0.5 mg - 1.5mg. . .nurse administered 1mg. . .patient passed away shortly after visit. . . –unknown reporter role	8	0.5
Unclear	It is unclear from the free-text description what level of harm has occurred	Pt [patient] had syringe driver [CSCI] with Midazolam 20mg, Haloperidol 5mg and Morphine 10mg. . .over last 24hrs patient required x4 prn doses of Midazolam; 3 x 5mg doses & 1x10mg dose. . .totalling 25mg of PRN [as needed] doses given over 24hrs, additional 20mg in syringe driver. . . now asking if DN [district nurse] can visit patient and increase drugs to: 50mg Midazolam, 10mg Haloperidol and 20mg Morphine over 24hr. . .set up an additional syringe driver. . .with 150mg Levomepromazine. . .explained. . . no decision to set up anticipatory syringe drivers. . .concerned regarding dose. . . –unknown reporter role	39	3