Improving patient safety and minimising patient harm

Key Points
  • Potent opioid analgesics are frequently involved in serious medication incidents, often because of incorrect dose calculations.
  • The National Reporting and Learning System (NRLS) collects, analyses and learns from all types of patient safety incidents.
  • NHS England encourages all patient safety incidents to be reported through the NRLS.
  • The acute sector reports the largest number of medication incidents with far fewer reports from primary care.1

 

Medication errors

Opioid analgesics are frequently involved in serious medication errors and are frequently implicated in serious errors to the NHS Litigation Authority, the Medical Defence Union, and the dispensing error analysis scheme. Morphine is one of the most frequently involved drugs in medication errors in other countries too, including the United States and Sweden. 3-5 In the National Patient Safety Agency (NPSA) report ‘Safety in doses: medication safety incidents in the NHS’ published in July 2007, opioids were highlighted as being one of the most implicated in medication incidents resulting in severe harm or patient death. 2

 

Reporting adverse events

Reports of suspected Adverse Drug Reactions should be made through the Yellow Card website, hardcopy form, smartphone app or using your clinical IT system where feasible).

 

 Safeguarding

Although the appropriate treatment of the patient is the focus of any healthcare event, when prescribing opioids, it is essential to consider whether there are risks beyond the patient.

Safeguarding issues concerning medication, e.g., diversion and coercion, and individuals around the patient, e.g., children, carers, and other vulnerable persons should be considered.

Be familiar with local adult and safeguarding policies and support systems. Consider prescribing frequency and volume and discuss with the patient and carers the need for clear, safe, and straightforward guidance.

Follow General Medical Council guidance on ‘Controlled drugs and other medicines where additional safeguards are needed’. 5

 

References:

  1. National patient safety incident reports up to June 2022. NHS England. https://www.england.nhs.uk/publication/national-patient-safety-incident-reports-up-to-june-2022/ Accessed 24/10/2023.
  2. Cousins, D., Gerrett, d. & Warner. (2013), A review of controlled drug incidents reported to the NRLS over seven years. The Pharmaceutical Journal, online. DOI:10.1211/PJ.2013.11125507
  3. Santell, J.P., Hicks, R.W., McMeekin, J. and Cousins, D.D. (2003), Medication Errors: Experience of the United States Pharmacopeia (USP) MEDMARX Reporting System. The Journal of Clinical Pharmacology, 43: 760-767. https://doi.org/10.1177/0091270003254831
  4. Nydert, P, Kumlien, A, Norman, M, Lindemalm, S. Cross-sectional study identifying high-alert substances in medication error reporting among Swedish paediatric inpatients. Acta Paediatr. 2020; 109: 2810–2819. https://doi.org/10.1111/apa.15273
  5. Säfholm, S., Bondesson, Å. & Modig, S. Medication errors in primary health care records; a cross-sectional study in Southern Sweden. BMC Fam Pract 20, 110 (2019). https://doi.org/10.1186/s12875-019-1001-0
  6. https://www.gmc-uk.org/professional-standards/the-professional-standards/good-practice-in-prescribing-and-managing-medicines-and-devices/controlled-drugs-and-other-medicines-where-additional-safeguards-are-needed

 

Further Reading 

Other resources in this section

Opioids Aware homepage