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Reducing dosing errors with opioid medicines

Reducing dosing errors with opioid medicines
Reference number
1066
Central Alert System (CAS) reference
NPSA/2008/RRR005
Issue date04 July 2008
Action date (if applicable) (date field)30 January 2009
DH Gateway reference
10157
TypeAlert

This Rapid Response Report alerts all healthcare professionals prescribing, dispensing or administering opioid medicines to the risks of patients receiving unsafe doses.


Every member of the team has a responsibility to check that the intended dose is safe for the individual patient. Knowledge of previous opioid dose is essential for the safe use of these products. There is a wide variety of opioid medicines, and supply shortages may result in products being used which are unfamiliar to practitioners.


The National Reporting and Learning System (NRLS) received reports of five deaths and over 4,200 dose-related patient safety incidents concerning opioid medicines up to June 2008.


This guidance applies to the prescription, dispensation or administration of buprenorphine, diamorphine, dipipanone, fentanyl, hydromorphone, meptazinol, methadone, morphine, oxycodone, papaveretum, pethidine.


When prescribing, dispensing or administering these medicines the healthcare practitioner or their clinical supervisor should:


  • Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient.
  • Ensure where a dose increase is intended, that the calculated dose is safe for the patient.
  • Check the usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, and common side effects of that medicine and formulation.

 

Healthcare organisations should review local medicines and prescribing policies, including Standard Operating Procedures, to reflect this guidance.

 

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.

 

Reducing the risk of mis-selecting opioid preparations in electronic systems (September 2009)

NHS Connecting for Health, working closely with the National Patient Safety Agency, has authored a paper which identifies lessons learned that might be applied to reduce the risk of mis-selection of opioid products.

The paper is likely to be of interest to both individuals involved in the design and implementation of ePrescribing systems, and those who use them.

 

Lessons learnt on mis-selection of opioid products (PDF, 138KB)

 

 

 

Opioid Medicines - Rapid Response Report
Opioid Medicines - Rapid Response Report - 34 KB 1066 - Opioid Medicines - Rapid Response Report - 2008-07-04 - V1
Opioid Medicines - Rapid Response Report supporting information
Opioid Medicines - Rapid Response Report supporting information - 359 KB 1066A - Opioid Medicines - Rapid Response Report supporting information - 2008-07-04 - V1