1. Audit Opioid use in palliative patients on general hospital wards
Dr Helen Mitchell
Hospital Palliative Care Team
Cardiff and Vale University LHB

2. Background Strong opioids commonly used on general wards Acute pain
Post-op pain
Vascular insufficiency
Cardiac chest pain
Breathlessness
Cancer

3. Controlled drug prescribing
Guidance
Junior doctor ‘pocket guides’
BNF
Anaesthetic department guidelines
Hospital formularies
Palliative textbooks / web pages
Palliative care teaching
Legal requirements

4. 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

5. Why this study? Clinical incident occurred
Incorrect dose of Sevredol was administered
Other instances?

6. Aim
Review prescriptions for strong opioids for patients known to the hospital palliative care team and note any discrepancies

7. 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’

8. 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

9. Results 23 events Medical 12 Surgical 11 Malignancy 18
UHW 20
Llandough 3
Medical 12
Haematology 5
Surgical 11
General surgery 9
Head & neck 1
Orthopaedics 1
Malignancy 18
Surgical 7
Medical 6
Haem 5
Non malignancy 5
Surgical 4
Medical 1

10. Opioids prescribed Prescription No of events Morphine injection 2
Morphine s/c driver 7
Oral morphine 6
Oxycodone s/c driver 1
Oral oxycodone 4
Fentanyl patch
Fentanyl ‘lozenge’

11. Types of problems identified
Event relating to:
Medical
Surgical
Regular dose 4 3
PRN dose
Co-analgesics 1 2
Omitted dose
Supply
Documentation
Other

12. Problems with regular opioid prescriptions
Related to: Administration 6
Prescribing 4

13. 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

14. 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

15. Problems with ‘PRN’ opioids
Administration 4
Prescribing 2

16. 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

17. 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)

18. Co-analgesics Frequent combinations with strong opioids Tramadol
Co-codamol

19. 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

20. Future action Ongoing education Issues to address Re-audit next year?
Rationale of WHO analgesic ladder
Appropriate (and legal) PRN medication use
Opioid conversions
Assessing suspected opioid toxicity
Re-audit next year?

21. 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

22. Lessons Learned Need for vigilance from ‘expert’ teams
Need for ongoing education and support
doctors
nursing staff
pharmacists

23. References
Hanks GW. Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer 2001; 84(5):
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.

24. Thank you