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Unsafe opioid replacement therapy in England and Wales: a mixed-methods study

Gibson, Russell, Azfal, Maryam, Williams, Huw, Edwards, Adrian, Hibbert, Peter, Sheikh, Aziz, Donaldson, Liam and Carson-Stevens, Andrew ORCID: 2017. Unsafe opioid replacement therapy in England and Wales: a mixed-methods study. The Lancet 389 (S1) , S38. 10.1016/S0140-6736(17)30434-8

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Background: The UK has the highest prevalence of illicit drug use in developed countries. Opioid replacement therapy (ORT) aims to reduce illicit opioid use, but inadequate monitoring of treatment can lead to serious preventable adverse drug reactions. We undertook a mixed-methods observational study of unsafe care received by adult patients receiving ORT in primary care. Methods: The National Reporting and Learning System collates all patient safety incident reports written by health-care professionals in England and Wales. We searched all primary care reports from April 1, 2005, to Sept 30, 2013, for the truncated terms “meth*” and “bupre*”. Free-text reports were read by clinical reviewers (RG, MA) and characterised with codes to describe what happened, underlying causes, harm outcome, and severity. Exploratory descriptive and thematic analyses were done to identify factors underpinning unsafe care. Findings: We identified 282 incidents of unsafe care, with 223 involving methadone and the rest buprenorphine (59). Over half (153) of reports described harm. Incidents occurred at every stage of providing ORT: prescribing (47), dispensing (148), and monitoring and communication of compliance (76). Dispensing errors occurred because of human error (46) and staff not following protocols (30)—for example, dispensing methadone as take out instead of supervised consumption. Monitoring failures led to patients being dispensed methadone despite three consecutive missed doses (which should trigger re-titration) and patients having duplicate prescriptions. Failures in communication between services underpinned many errors. This study is the largest characterisation, to our knowledge, of unsafe care for patients undergoing ORT in primary care. Although incident reporting systems are prone to under-reporting, our results pinpoint clear ways to improve systems and processes throughout the National Health Service. The unsafe care identified in our study would have been largely prevented by centralised medication record systems, automated alerts for missed doses, electronic prescriptions, and pharmacy team safety meetings.

Item Type: Article
Date Type: Publication
Status: Published
Schools: Medicine
Publisher: Elsevier
ISSN: 0140-6736
Last Modified: 23 Oct 2022 13:16

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