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Audit
Opioid use in palliative patients
on general hospital wards
Dr Helen Mitchell
Hospital Palliative Care Team
Cardiff and Vale University LHB
Background
• Strong opioids commonly
used on general wards
–
–
–
–
–
–
Acute pain
Post-op pain
Vascular insufficiency
Cardiac chest pain
Breathlessness
Cancer
Controlled drug prescribing
• Guidance
– Junior doctor ‘pocket guides’
– BNF
– Anaesthetic department guidelines
– Hospital formularies
– Palliative textbooks / web pages
– Palliative care teaching
• Legal requirements
Controlled drug regulation
• Medicines Ethics and Practice: A guide for
pharmacists and pharmacy technicians
Royal Pharmaceutical Society of Great Britain 2009
• Safer Management of Controlled Drugs: A guide
to good practice in secondary care (England)
Department of Health 2007
• Standards for Medicines Management
Nursing Midwifery Council 2008
Why this study?
• Clinical incident
occurred
• Incorrect dose of
Sevredol was
administered
• Other instances?
Aim
• Review prescriptions for strong opioids for
patients known to the hospital palliative
care team and note any discrepancies
Setting standards
• All prescription/administration of controlled
drugs should conform to:
– Legal requirements
– EAPC guidance on use of morphine and
alternative opioids (2001)
– locally accepted ‘good practice’
Study design
• Prospective review of hospital prescription
charts - patients known to Hospital
Palliative Care Team at Llandough
Hospital and University Hospital of Wales
• 3 month period
• Data recording sheet completed by HPCT
member if ‘incident’ noted
• Issue discussed with relevant ward staff
and action / outcome recorded
Results
• 23 events
– UHW 20
– Llandough 3
• Malignancy
18
– Surgical 7
– Medical 6
– Haem 5
• Medical 12
– Haematology 5
• Surgical 11
– General surgery 9
– Head & neck 1
– Orthopaedics 1
• Non malignancy 5
– Surgical 4
– Medical 1
Opioids prescribed
Prescription
Morphine injection
Morphine s/c driver
Oral morphine
Oxycodone s/c driver
Oral oxycodone
Fentanyl patch
Fentanyl ‘lozenge’
No of events
2
7
6
1
4
2
1
Types of problems identified
Event relating to: Medical Surgical
Regular dose
4
3
PRN dose
4
3
Co-analgesics
1
2
Omitted dose
2
1
Supply
1
Documentation
1
Other
1
Problems with regular opioid
prescriptions
Related to:
Administration
Prescribing
4
6
Administration - regular opioids
•
•
•
•
•
10 pm dose withheld; ‘patient too drowsy’
4 hourly dose withheld; ‘patient confused’
10 pm dose not signed for
Fentanyl patch removed but not replaced
Patient self-administered syringe driver
medication due to severe pain
• Syringe driver not set up because of
incompatible drug volume
Prescribing - regular opioids
• Usual dose stopped; ‘patient unwell’
• Usual dose not charted on admission;
‘patient vomiting’
• Syringe driver dose incorrectly prescribed
for 48 hours
• Incorrect switch from oral to syringe driver
(opioid toxicity)
• Incorrect switch from syringe driver to oral
Problems with ‘PRN’ opioids
• Administration 4
• Prescribing
2
Administration - PRN doses
• Prescribed dose not given accurately
– more or less?
• Patient incorrectly advised of PRN dose
on discharge (‘Take 2 tabs’ but stronger
strength prescribed & dispensed)
• Patient in pain but no PRN doses given
Prescribing - PRN doses
• Oral oxycodone changed to IM morphine
• Concern that PRN dose used frequently,
but ‘inappropriately’ low dose prescribed
(morphine liquid 10 mg PRN with oral
morphine equivalent 160 mg/24 hrs)
Co-analgesics
• Frequent combinations with strong opioids
– Tramadol
– Co-codamol
Action taken
• Each incident risk assessed
• Discussion / education
– Ward staff teaching
– Clinical incident forms completed if indicated
• Clinical governance issues addressed
• Targeted education session by HPCT
consultant to ward staff
Future action
• Ongoing education
• Issues to address
– Rationale of WHO analgesic ladder
– Appropriate (and legal) PRN medication use
– Opioid conversions
– Assessing suspected opioid toxicity
• Re-audit next year?
Lessons learned
• Safe use of opioids
for palliative patients
may prove difficult on
general hospital
wards
• Despite available
teaching and
guidance,
discrepancies and
errors occur
Lessons Learned
• Need for vigilance
from ‘expert’ teams
• Need for ongoing
education and
support
– doctors
– nursing staff
– pharmacists
References
• Hanks GW. Morphine and alternative opioids in
cancer pain: the EAPC recommendations.
Br J Cancer 2001; 84(5): 587-93
• Cardiff and Vale NHS Trust. Procedure for
ordering, storage and safe administration of
controlled drugs. Nov 2003.
• The ‘How to Guide’ for Improving Medicines
Management: Preventing Harm from High-Alert
Medications in Secondary Care.
www.1000livescampaign.wales.nhs.uk
Thank you