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National Patient Safety Agency

Healthcare practitioners alerted to concerns over incorrect use of powerful pain killers

7 July 2008


The NPSA is issuing a Rapid Response Report to healthcare practitioners in the UK following concerns over incorrect and unsafe dosing of opioids, powerful pain killers (such as morphine, methadone, oxycodone and fentanyl), which are used to relieve severe pain.


From January 2005 to June 2008, the NPSA had reports of five deaths and 4,200 dose-related incidents concerning opioid medicines.  It is very likely that many similar cases have occurred but have gone unreported.


Opioids are widely used across all sectors of the NHS including hospitals and in the community.  In the primary care setting alone there has been a 62% increase in opioid use in England between 2001 to 2006 [1].


The cases reported to the NPSA include prescribing error – one patient was given 100mg of morphine instead of 10mg which could have resulted in respiratory depression and death. Another was given a 24 hour dose of diamorphine as a single injection instead of a small dose every four hours, this caused severe harm and could have resulted in death.


This Rapid Response Report requests that health practitioners follow new guidance when prescribing, dispensing or administering opioid medicines to ensure the following:


  • Confirm any recent opioid dose


  • Ensure that dose increments are appropriate


  • Ensure they are familiar with the correct use of the drug and recognise common side effects and symptoms of overdose.


Dr Bruce Warner, Senior Pharmacist at the NPSA, said: “As the use of opioids across the NHS increases it is vital that we ensure safe doses are administered. Opioids are very strong pain killers and the wrong dose could be fatal. Every member of the healthcare team has responsibility to check that the intended dose is safe for the individual patient.  Knowledge of previous opioid dose is essential.  This Rapid Response Report will help raise awareness of some common errors that have occurred across NHS settings in recent years with an aim of ensuring safer use in the future.”


Speaking about the importance of implementing this guidance, Jonathon Mason, Head of Prescribing and Pharmacy from City and Hackney Primary Care Trust, said: "These are powerful medicines used by patients who are very vulnerable.  They are prescribed and administered by a range of staff across different settings.  Dosing errors can occur when patients are discharged from hospital or are being treated by different staff.  This guidance is very much welcome and will help to protect some of these vulnerable patients and make errors less likely." 


View the Rapid Response Report


[1] NHS Business Services Authority (Prescribing Pricing Division)

(Reporting quarter = October-December 2006, Index quarter = October-December 2001)




Notes for editors:


Media enquiries to Amelia Lyons in the NPSA Communications Department on 0207 927 9580, amelia.lyons@npsa.nhs.uk or Paul Cooney on: 0207 927 9351, paul.cooney@npsa.nhs.uk


The National Patient Safety Agency encompasses the National Research Ethics Service, Patient Safety Division and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes.


National Reporting and Learning System (NRLS)

The NPSA collects and analyses reports of patient safety incidents received from NHS staff through its National Reporting and Learning System (NRLS).  This data includes all patient safety incidents reported from NHS organisations in England and Wales.  The findings are then reported back to the NHS and the public via regular alerts (such as the Rapid Response Report), quarterly data summary and bulletins, with the aim of improving patient safety. 


All NHS organisations have been connected to the NRLS since January 2005 and more than 2 million incidents have been received to date.  We also receive reports via our service eform from NHS Direct and community pharmacies.


It is important to note that volume of reports received by the NRLS has steadily increased since inception and as the NRLS is a voluntary reporting system, the data may not be representative of the rates of incidents across England and Wales.


Rapid Response Reports

Since June 2007, the NPSA has been issuing one-page notices with supporting information to NHS organisations about risks to patients. These are called Rapid Response Reports and eight have been issued to date.  These are issued to all NHS organisations, in England and Wales, presenting the evidence of harm to patients and identifying clear actions to reduce risks.