Authors
  • Nicole Heneka1,
  • Jane Phillips2,
  • Tim Shaw3,
  • Debra Rowett4,
  • Sam Lapkin2
Organisations
  • University of Notre Dame1,
  • University of Technology Sydney (UTS)2,
  • University of Sydney3,
  • Repatriation General Hospital, Adelaide4
Year

2016

Excerpt

Background: Patients at the end of life are at greater risk of medication errors due to the seriousness of   their illness and the complexity of their treatment regimens, compounded by multiple routes of administration and dosing schedules. Opioids are high-risk medicine, used routinely in palliative care services to manage complex pain and symptoms at the end of life, and are the most frequently reported drug class in medication errors causing patient harm. Despite their widespread use, there is little empirical research on opioid medication error types and patient impact in palliative care services, beyond deviations from opioid prescribing guidelines.

Aim: To identify the types, frequency and patient impact of reported opioid medication errors in three specialist, adult palliative care services over 24 months.

Methods: A quality audit of incidents and errors involving opioids, reported via the internal incident management system, in three specialist palliative care services in New South Wales, (NSW).

Results: Preliminary data analysis has identified 128 incidents involving opioids, of which 55% (n=70) reached the patient. All errors were categorised as either severity assessment code (SAC) 3 (55%) or SAC 4 (45%). Administration errors were the predominant error type reported (44%, n=56), followed by controlled drug discrepancy errors (27%, n=34), drug storage/wastage errors (12%, n=15) and prescribing errors (7%, n=9). The three most common administration error types were: omitted opioid doses (14%, n=18), wrong dose (12%, n=15) or wrong drug (9%, n=12) administered. Transdermal patch errors accounted for 6% (n=8) of administration errors. Morphine (32%) and hydromorphone (30%) were implicated in the majority of opioid errors. Missed opioid administration (under-­‐dose) accounted for 46% of the errors that reached the patient contributing to 18% of these patients experiencing sub-optimal pain management and requiring additional analgesia administration.

Conclusions: This preliminary data has identified the range of opioid errors reported in specialist palliative care extends beyond prescribing strategy errors.

Identifying and quantifying opioid medication error types, incidence and patient impact (1.58MB pdf)