The National Patient Safety Agency (NPSA) has advised the NHS in England and Wales to review and improve measures for prescribing, storing, administering and identifying high doses of morphine and diamorphine.
Between 2000 and 2005 seven case reports were published of deaths due to the administration of high dose diamorphine or morphine to patients who had not previously received doses of opiates. These case reports prompted the NPSA to review reports in the National Reporting and Learning System on the same subject. Between January and October 2005 the NPSA received 16 reports of similar patient safety incidents, two of which resulted in deaths.
Many of these incidents involved diamorphine and morphine 30 mg ampoules being selected in error for lower strength ampoules and causing overdoses. Overdoses of morphine or diamorphine can cause breathing problems, unconsciousness and, in rare cases, be fatal. Some other incident reports highlighted problems with high doses of these medicines being given mistakenly to patients who had not previously received lower doses of the opiates and had not built up a tolerance to the medication. In these cases, the patient’s lack of tolerance meant that the dose was too high for them.
To help staff guard against errors, the NPSA has issued a Safer Practice Notice (SPN) to all NHS organisations advising them to put measures in place to protect patients from simple but potentially fatal mistakes. The actions are: • Risk assess and have procedures in place for safely prescribing, labelling, supplying, storing, preparing and administering diamorphine and morphine injection material.
• Review therapeutic guidelines for the use of diamorphine and morphine injectable products for patients requiring acute care, including post administration observation of patients who have not previously received doses of opiates. • Update information concerning the safe use of diamorphine and morphine injectable products as part of an ongoing programme of training for healthcare staff on medicine practice.
• Ensure that naloxone injection, the antidote to opiate-induced respiratory depression, is available in all clinical locations where diamorphine and morphine injections are stored or administered.
The NPSA’s medical director, Professor Sir John Lilleyman, said: “Morphine and diamorphine are vital elements of treatment for many conditions and incidents relating to the use of these drugs are very rare. However, as our reporting system shows, patients can be harmed by mistakes that are easily avoidable. We urge organisations to act quickly to implement the recommendations of the Safer Practice Notice.
“This Safer Practice Notice illustrates the value and importance of the reports that staff make to the NRLS: if we are aware of problems then we can take action to help stop them happening again. By reporting mistakes or failures in patient care, locally and nationally, healthcare staff can help the NHS learn about and address these problems.”
The Medicines and Healthcare products Regulatory Agency (MHRA) has agreed changes to the packaging of all opiates to make it easier for staff to tell different strengths of morphine and diamorphine apart.
Patients requiring higher doses of morphine and diamorphine for palliative care purposes will still receive the medication they need and are not affected by the SPN recommendations.
