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

The French National Authority for Health (HAS) released a landmark report on September 16, 2026, revealing that over 70% of Serious Adverse Events (EIGS) occurring in end-of-life care settings are classified as preventable or likely preventable. This finding emerges against a backdrop of increasing scrutiny regarding palliative care standards and comes shortly after the organization’s annual report highlighted a 20% surge in overall EIGS declarations by healthcare professionals throughout 2025.

The investigation, which spanned data collected from the inception of the national reporting system in March 2017 through September 2025, represents the first dedicated analysis of its kind by the authority. By narrowing down 1,898 initial reports to 385 verified cases of end-of-life patient harm, the HAS has provided a sobering look at the clinical and organizational failures that compromise the final stages of life for thousands of patients.

A Chronology of Systemic Oversight

The impetus for this deep dive was a confluence of legislative debate and a recognized need to improve safety protocols within palliative care. In early 2025, as national discussions surrounding the ethics and practice of end-of-life care reached a fever pitch, the HAS prioritized the synthesis of years of data.

Between March 2017 and September 2025, the national device for reporting EIGS—defined as events resulting in death, life-threatening danger, or permanent functional impairment—began accumulating records of incidents occurring during palliative transitions. The research team spent the first half of 2025 refining these entries, discarding incomplete or off-topic reports to isolate 385 cases that met the strict criteria for "end-of-life" or "palliative approach" contexts. The publication of this report on September 16, 2026, serves as both an audit of the previous decade of care and a roadmap for urgent reform.

Demographics and Clinical Context

The 385 analyzed cases painted a clear picture of the patient population most at risk. The majority were over the age of 60, with 42% falling between the 60 and 80 age bracket, and 38% aged between 80 and 100. Gender distribution showed a slight skew, with 46% of the impacted patients being women.

The clinical profile of these patients revealed the high-acuity nature of their care needs:

• Oncology patients: 65% of the cases involved patients battling cancer, reflecting the high volume of palliative care intervention in this sector.
• Neurological conditions: 13% of reports involved patients with progressive neurodegenerative diseases.
• Organ failure: 12% involved advanced stage-four organ failure.
• Polypathology: 8% involved elderly patients with multiple, complex comorbidities.

The high proportion of preventable harm—71%—is statistically jarring when compared to the average rate of preventability in general healthcare settings, which typically fluctuates between 50% and 60%. As Candice Legris, Deputy Head of the Evaluation and Tools for Quality and Safety of Care service at the HAS, noted, this figure is "particularly elevated," signaling that the transition to palliative care is currently fraught with avoidable hazards.

Dissecting the Causes: Immediate vs. Systemic

The HAS report employs a "Swiss Cheese Model" approach, distinguishing between the immediate errors that triggered an event and the deeper, systemic causes that allowed those errors to occur.

Immediate Causes (88% of cases):
The most frequent triggers for serious adverse events were rooted in the mechanics of care delivery. Organizational failures—specifically breakdowns in communication, coordination, and surveillance—accounted for 32% of events. Medication errors followed closely at 28%, and equipment-related malfunctions, particularly involving infusion pumps and electric syringe drivers, accounted for 25%.

Deep-Rooted Systemic Factors:

• Patient Complexity: In 79% of cases, the complexity of the patient’s condition or their multi-drug regimen contributed significantly to the failure.
• Protocol Adherence: 70% of incidents were linked to issues with "tasks to perform," such as outdated, unavailable, or ignored clinical protocols.
• Human Factor: 66% of cases involved staff-related issues, including a lack of specialized training or insufficient experience in handling high-risk palliative medications.
• Work Environment: 58% of reports cited environmental stressors, such as critical understaffing, excessive workload, or faulty medical hardware.

The Medication Safety Crisis

A critical revelation in the report is the alarming frequency of errors involving high-risk drugs, such as morphine and other potent sedatives. There were 81 documented cases of medication overdose, often resulting from miscalculations or the incorrect programming of administration devices.

"It was quite impressive to see the extent to which there are so many medication errors linked to these high-risk products," Legris stated. The HAS emphasizes that these are not merely "human errors" stemming from incompetence. Instead, they are the result of high-risk drugs being managed in high-stress, under-resourced environments. The authority is calling for a standardization of preparation protocols and mandatory double-verification for all dosage calculations and pump settings.

Recommendations and Future Policy Shifts

To mitigate these risks, the HAS has proposed a series of urgent interventions. Beyond the technical focus on medication safety, the authority insists on the "regular reassessment of the patient’s state." Because end-of-life conditions are dynamic and can deteriorate rapidly, the traditional cadence of patient monitoring is often insufficient.

The HAS suggests that clinical reassessments must be more frequent and better coordinated across multidisciplinary teams. The challenge, however, remains implementation. When asked how these recommendations might be enforced, Legris suggested that the authority might incorporate these safety benchmarks into official healthcare certification manuals or the formal evaluation criteria for medico-social establishments.

Broader Implications for the Healthcare System

This report arrives at a critical juncture for the French health system. By linking the rise in adverse events to the increased pressure on clinical staff and the complexity of modern palliative medicine, the HAS has provided a data-driven justification for deeper investment in specialized palliative training and better-integrated electronic health records.

The implications are clear: the shift toward more personalized, human-centric end-of-life care requires a corresponding shift toward rigid, automated safety protocols. The "preventable" nature of these 272 cases—144 of which resulted in death and 118 of which threatened a patient’s life—suggests that thousands of patients could have experienced a significantly different final chapter of life had these systems been in place.

As policymakers continue to debate the legislative framework for end-of-life care, this report serves as a reminder that the quality of the journey is as important as the legal framework surrounding it. Ensuring that palliative care is delivered with the highest degree of safety is not just a clinical goal; it is a moral imperative for a healthcare system tasked with providing dignity in the final moments of existence.

With the simultaneous release of a separate report on EIGS in Ehpad (nursing homes), the HAS is clearly signaling a broad, multi-front campaign to tighten safety nets across the entire spectrum of long-term and palliative care. Whether these recommendations lead to a measurable reduction in preventable harm by 2027 will depend on the willingness of individual facilities to overhaul their internal organizational structures and prioritize the safety of their most vulnerable patients.