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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