Fin de vie : 7 événements indésirables sur 10 jugés évitables ou probablement évitables (HAS)

The French National Authority for Health (HAS) has released a landmark report on September 16, 2026, shedding light on the critical safety vulnerabilities within end-of-life and palliative care settings. The findings reveal a sobering reality: 71% of serious adverse events associated with care (EIGS) occurring in patients at the end of their lives were classified as avoidable or potentially avoidable. This analysis, the first of its kind conducted by the authority, arrives at a time of intense national and international debate regarding the medical, ethical, and logistical management of the final stages of life.

Context and Scope of the Investigation

The report builds upon broader data released by the HAS earlier in the week, which indicated a 20% surge in the total number of serious adverse events declared by healthcare professionals in 2025. Faced with this upward trend, the HAS initiated a deep-dive analysis of its national database, specifically filtering for entries involving end-of-life contexts and palliative care pathways.

The investigation spanned data collected from the inception of the national reporting system in March 2017 through September 2025. Out of 1,898 initial declarations that mentioned end-of-life or palliative care, researchers refined the data to 385 high-quality, actionable reports. By stripping away incomplete or irrelevant filings, the HAS was able to construct a clear profile of the systemic failures affecting some of the most vulnerable patients in the healthcare system.

The patient demographic identified in these 385 cases highlights the complexity of modern end-of-life care. Approximately 46% of the affected patients were female, and the vast majority were over the age of 60. Specifically, 42% of the incidents involved patients between 60 and 80 years old, while 38% occurred in patients aged 80 to 100. The clinical profiles were equally complex: 65% of the patients suffered from cancer, 13% had progressive neurological disorders, 12% were dealing with advanced organ failure, and 8% presented with multi-pathology conditions typical of advanced age.

Chronology of Findings and Data Breakdown

The gravity of these events is underscored by their outcomes. Of the 272 events deemed preventable, 144 (53%) resulted in the death of the patient. Furthermore, 118 (43%) compromised the patient’s vital prognosis, and 10 (4%) resulted in permanent functional deficits. Candice Legris, Deputy Head of the Service for Evaluation and Tools for Quality and Safety of Care at the HAS, noted that the proportion of preventable events in this sector is "particularly high," notably exceeding the typical 50-60% range observed in general clinical settings.

The HAS categorizes these failures into two distinct tiers: "immediate causes" and "deep-seated systemic factors."

Immediate causes were identified in 88% of the analyzed cases, with organizational failures (32%), medication errors (28%), and equipment-related malfunctions (25%) leading the list. Organizational failures were frequently characterized by a lack of coordination between care teams or lapses in patient monitoring. Medication errors were heavily concentrated in the administration of sedatives and analgesics, with 81 recorded cases of overdosage. Equipment failures almost exclusively involved the technology used to administer these potent drugs, specifically electric pumps and syringe drivers.

The "deep-seated" causes revealed a broader structural crisis. Patient-related factors—such as extreme clinical instability and the complexity of polypharmacy—were cited in 79% of reports. Issues regarding task execution (70%), such as the failure to update or correctly apply clinical protocols, and professional factors (66%), such as insufficient training or experience, rounded out the primary drivers of error. Perhaps most telling is that 58% of reports identified the working environment itself—characterized by excessive workloads, staff shortages, and suboptimal equipment—as a direct contributor to the adverse event.

Official Responses and Strategic Recommendations

The HAS has identified the secure management of high-risk medications as a primary pillar for intervention. During an interview with APMnews, Legris emphasized the shock felt by investigators regarding the frequency of errors involving substances like morphine. "It was quite impressive to see the extent to which there are so many medication errors linked to these high-risk products," she stated.

The authority’s recommendations include:

• Verification Protocols: Implementing a mandatory double-check system for dosage calculations and the programming of automated infusion devices.
• Standardization: Developing uniform, institutionalized methods for the preparation of high-risk drugs to minimize variability in clinical practice.
• Training and Competency: Ensuring that staff are not merely trained but are actively assessed on their proficiency in using complex medical equipment.

However, the HAS is careful to avoid a "blame culture." Legris noted that these errors should not be reduced to a lack of professional competence, as these are inherently high-risk products that are technically difficult to handle. Instead, the focus must shift to structural improvements in storage, prescription workflows, and organizational support.

A second major recommendation focuses on the dynamic re-evaluation of patients. In palliative care, clinical conditions can shift rapidly. The reports indicated that current practices often fail to keep pace with these changes, leading to instances where pain management or sedation is either insufficient or inappropriately aggressive. The HAS advocates for more frequent, systematic re-evaluations to ensure that the intensity and nature of care remain aligned with the patient’s evolving clinical status.

Implications for the Healthcare System

The publication of this report comes at a critical juncture. As France and other nations debate the legal framework surrounding end-of-life care, the HAS data serves as a stark reminder that even within existing palliative structures, the quality of care is threatened by systemic, rather than purely medical, deficiencies.

The integration of these findings into broader policy remains a point of discussion. The HAS is currently exploring ways to embed these safety requirements into the certification manuals for hospitals and the mandatory evaluations for medico-social institutions (such as Ehpad, the French nursing homes). While the implementation process remains subject to ongoing dialogue with stakeholders, the objective is clear: to transform the findings from a list of failures into a roadmap for safer, more humane end-of-life care.

This report is part of a wider effort by the HAS to improve safety culture, including a parallel, recently published report on adverse events in nursing homes. As the healthcare system faces an aging population and increasing demand for palliative support, the ability to eliminate these "preventable" errors will become a defining metric of the quality of public health. By highlighting the nexus between organizational culture, equipment safety, and clinical vigilance, the HAS has provided a comprehensive, evidence-based foundation for necessary reforms in a sector where the margin for error is virtually non-existent.