This document alerts the NHS in England and Wales to review and improve measures for safer practice in prescribing, storing, administering and identifying high dose morphine and diamorphine injections. It advises all NHS organisations to put measures in place to protect patients from simple but potentially fatal mistakes.
There have been a number of reports of deaths and harm due to the administration of high dose (30mg or greater) diamorphine or morphine injections to patients who had not previously received doses of opiates.
The main risks have been identified as: lookalike / similar packaging for different strengths of diamorphine and morphine ampoules; poorly differentiated outer cartons and ampoules; higher and lower strength ampoules of diamorphine and morphine stored together in clinical areas in both primary and secondary care; and insufficient therapeutic training and understanding by healthcare staff of the risks and precautions when prescribing, dispensing and administering higher doses of these medicines.
The document sets out background information, the actions required, and how to implement these whilst ensuring urgent access to palliative care drugs.
It is accompanied by a patient briefing in English and Welsh for patients being given morphine or diamorphine for the first time.