Identifying opioid error types and patient impact in specialist palliative care services: Preliminary results from a multisite quality audit. Nicole Heneka, 1 Tim Shaw, 2 Debra Rowett, 3 Samuel Lapkin, 4 and Jane L. Phillips. 5 This work was supported by an Australian Government, Collaborative Research Networks (CRN) program scholarship (NH) for the research project: Healthy People, Healthy Country. This preliminary data has identified the range of opioid errors reported in specialist palliative care extends beyond deviations from opioid prescribing guidelines, and provides a starting point for targeted quality improvement initiatives to support safe opioid medication practices in specialist palliative care services. 1. PhD Candidate, University of Notre Dame Australia, Darlinghurst, NSW, Australia; Email: [email protected] 2. University of Sydney, NSW, Australia 3. Repatriation General Hospital, Adelaide, SA, Australia 4. St George Hospital, Kogarah, NSW, Australia 5. University of Technology Sydney, NSW, Australia Background • Opioids are a high-risk medicine, used routinely in palliative care services to manage complex pain and symptoms at the end of life. • Despite their widespread use, there is little empirical research on opioid medication error types and patient impact in palliative care services, beyond deviations from opioid prescribing guidelines. 1 Preliminary Results Reported incidents/errors involving opioids (n=85) Incident/error type Narcotic discrepancy 22.4% (n=19) Drug storage/ wastage/ security 14.1% (n=12) Prescribing 12.9% (n=11) Near Miss 3.5% (n=3) Dispensing 1.2% (n=1) Patient factors 1.2% (n=1) Administration 44.7% (n=38) Omitted dose 34.2% Wrong dose 23.7% Transdermal patch error 18.4% Wrong drug 15.8% Syringe driver error 5.2% Wrong patient 2.6% Figure 1: Opioid incident/error type REFERENCES 1. Heneka, N., Shaw, T., Rowett, D., & Phillips, J. (2015). Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review. Palliative Medicine, 30(6), 520532. Aim and Methods Aim: To identify the types, frequency and patient impact of reported opioid medication errors in three specialist, adult palliative care services over 24 months. Methods: A quality audit of incidents and errors involving opioids, reported via the internal incident management system, in three specialist palliative care services in New South Wales. Implications for clinical practice and future research Patient impact • For 47% of patients, administration errors resulted in missed opioid administration (under-dose), resulting in sub-optimal pain management and increased analgesia requirements (17%), or other symptoms directly related to the under- dose (6%), e.g., shortness of breath. • Wrong dose errors led to symptoms of opioid toxicity in 15% of patients. Incident characteristics Preliminary data analysis identified 85 reported opioid incidents across the three services, of which 55% (n=47) reached the patient. Almost half of all incidents related to opioid administration (Figure 1), one third of which were omitted doses. Opioid conversion and medication charting errors resulted in the majority of prescribing incidents. Narcotic discrepancy incidents related primarily to volume discrepancies with liquid opioids. Opioid storage, wastage and security incidents included drug wastage due to breakage/spillage, and issues with patients’ own opioid medication storage. The three near-miss incidents reported related to potential wrong drug, wrong patient and medication charting errors. Two thirds of all incidents involved hydromorphone (37%) or morphine (23%). All incidents were classified as either Severity Assessment Code (SAC) 3 (47%) or SAC 4 (53%).

Identifyingopioiderrortypesandpatientimpactinspecialistpal ......Nicole Heneka,1 Tim Shaw, 2 Debra Rowett,3 Samuel Lapkin,4 and Jane L. Phillips.5 This work was supported by an Australian

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Page 1: Identifyingopioiderrortypesandpatientimpactinspecialistpal ......Nicole Heneka,1 Tim Shaw, 2 Debra Rowett,3 Samuel Lapkin,4 and Jane L. Phillips.5 This work was supported by an Australian

Identifying opioid error types and patient impact in specialist palliative care services: Preliminary results from a multi-site quality audit.Nicole Heneka,1 Tim Shaw,2 Debra Rowett,3 Samuel Lapkin, 4 and Jane L. Phillips.5

This work was supported by an Australian Government, Collaborative Research Networks (CRN) program scholarship (NH) for the research project: Healthy People, Healthy Country.

This preliminary data has identified the range of opioid errors reported in specialist palliative care extends beyond deviations from opioid prescribing guidelines, and provides a starting point for targeted quality improvement initiatives to support safe opioid medication practices in specialist palliative care services.

1. PhD Candidate, University of Notre Dame Australia, Darlinghurst, NSW, Australia; Email: [email protected]

2. University of Sydney, NSW, Australia3. Repatriation General Hospital, Adelaide, SA, Australia4. St George Hospital, Kogarah, NSW, Australia5. University of Technology Sydney, NSW, Australia

Background• Opioids are a high-risk medicine, used routinely in

palliative care services to manage complex pain and symptoms at the end of life.

• Despite their widespread use, there is little empirical research on opioid medication error types and patient impact in palliative care services, beyond deviations from opioid prescribing guidelines.1

Preliminary ResultsReported incidents/errors involving opioids (n=85)

Incident/errortype

Narcotic discrepancy 22.4% (n=19)

Drug storage/ wastage/ security 14.1% (n=12)

Prescribing12.9% (n=11)

Near Miss3.5% (n=3)

Dispensing1.2% (n=1)

Patient factors1.2% (n=1)

Administration44.7% (n=38)

Omitteddose34.2%

Wrong dose23.7%

Transdermal patch error18.4%

Wrong drug15.8%

Syringe driver error5.2%

Wrong patient2.6%

Figure 1: Opioid incident/error type

REFERENCES1. Heneka, N., Shaw, T., Rowett, D., & Phillips, J. (2015). Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review. Palliative Medicine, 30(6), 520-532.

Aim and MethodsAim: To identify the types, frequency and patient impact of reported opioid medication errors in three specialist, adult palliative care services over 24 months.Methods: A quality audit of incidents and errors involving opioids, reported via the internal incident management system, in three specialist palliative care services in New South Wales.

Implications for clinical practice and future research

Patient impact• For 47% of patients, administration errors resulted in missed opioid administration

(under-dose), resulting in sub-optimal pain management and increased analgesia requirements (17%), or other symptoms directly related to the under-dose (6%), e.g., shortness of breath.

• Wrong dose errors led to symptoms of opioid toxicity in 15% of patients.

Incident characteristicsPreliminary data analysis identified 85 reported opioid incidents across the three services, of which 55% (n=47) reached the patient. Almost half of all incidents related to opioid administration (Figure 1), one third of which were omitted doses. Opioid conversion and medication charting errors resulted in the majority of prescribing incidents. Narcotic discrepancy incidents related primarily to volume discrepancies with liquid opioids. Opioid storage, wastage and security incidents included drug wastage due to breakage/spillage, and issues with patients’ own opioid medication storage. The three near-miss incidents reported related to potential wrong drug, wrong patient and medication charting errors. Two thirds of all incidents involved hydromorphone (37%) or morphine (23%). All incidents were classified as either Severity Assessment Code (SAC) 3 (47%) or SAC 4 (53%).