Source: The CCQ 11.07.24
Learning from incidents
When we speak with organisations about medicines incidents, we focus on understanding the
circumstances surrounding them and what has been done to investigate, follow up and reduce
the chance of future recurrence.
Over the last year, we have heard about a range of cases that relate to 2 particular medicines: alfentanil and morphine. We share some of the learning from these incidents here.
Alfentanil medication errors
We have seen a recent increase in incidents relating to the incorrect selection of alfentanil – either in terms of prescribing or physically selecting a vial for administration. Alfentanil is a potent injectable opioid with a range of uses, including during anaesthesia and for some patients receiving palliative care. It is available as 500 micrograms/ml strength and 5 milligrams/ml strength (sometimes referred to as ’intensive care’ or ’high’ strength). The cases we have heard about involved wrongly selecting the ‘high’ strength.
Contributory factors have included poor knowledge and awareness of higher strengths, the competency of staff when making dose calculations, and storage of the high strength preparation on wards where it is not commonly needed or used.
Organisations have shared the following points of learning:
- It is important to make staff aware of the existence of a higher strength.
- Pharmacy teams and ward leaders should have oversight of where alfentanil is needed, used and stocked, and should query requests for stock from wards where it is not normally used.
- Risk assessments of the use of alfentanil can be useful, especially as it helps services to develop ways of mitigating risks of mis-selection or incorrect prescribing.
- Some services remove the higher strength from the ward when it is not needed.
Morphine sulfate – infant overdose
We are also aware of tragic circumstances surrounding overdoses of morphine in infants. In one example, morphine sulfate oral solution was administered at a dose 20 times higher than the intended dose. This happened because the infant’s parents were supplied with a 10 milligrams/5ml oral solution after discharge from the hospital, and not a 100 micrograms/ml solution. NHS England North East and North Yorkshire has produced a helpful case study with details of the causative factors and learning points to reduce the risk of future occurrences.
Points of learning included:
- Making morphine a ‘red’ drug in paediatrics so that responsibility for a prescription cannot be transferred to the community. This means supply would come from hospitals and specialist centres only.
- Discharge summaries should contain the full name of the drug, formulation, strength, and clear dose instructions with consideration of daily maximum doses for PRN (when required) medication.
- The importance of speaking directly to the prescriber for medication queries with high-risk drugs, and/or patients with complex conditions.
- When counselling, ask patients to summarise and recall main points back to you to check their understanding.
Click here for the source.
