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A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales

Gibson, Russell, MacLeod, Natalie, Donaldson, Liam J., Williams, Huw, Hibbert, Peter, Parry, Gareth, Bhatt, Jay, Sheikh, Aziz and Carson-Stevens, Andrew ORCID: 2020. A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. Addiction 115 (11) , pp. 2066-2076. 10.1111/add.15039

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Background & Aims: Opioid substitution treatment is used in many countries as an effective harm minimization strategy. There is a need for more information about patient safety incidents and resulting harm relating to this treatment. We aimed to characterise patient safety incidents involving opioid-substitution treatment with methadone or buprenorphine in community-based care by: (i) identifying the sources and nature of harm, and (ii) describing and interpreting themes to identify priorities to focus future improvement work. Design: Mixed-methods study examining patient safety incident reports involving opioid substitution treatment with either methadone or buprenorphine in community-based care. Setting: Data submitted between 2005 and 2015 from the National Reporting and Learning System (NRLS), a national repository of patient safety incident reports from across England and Wales. Participants: 2,284 reports were identified involving patients receiving community-based opioid substitution treatment. Measurements: Incident type, contributory factors, incident outcome and severity of harm. Analysis involved data coding, processing and iterative generation of data summaries using descriptive statistical and thematic analysis. Findings: Most risks of harm from opioid substitution treatment came from failure in one of four processes of care delivery: prescribing opioid-substitution (n=151); supervised dispensing (n=248); non-supervised dispensing (n=318); and monitoring and communication (n=1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n=91/127, 72%). Staff- (e.g. slips during task execution, not following protocols) and organisation-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were identified for over half of incidents. 3 Conclusions: Risks of harm in delivering opioid-substitute treatment in England and Wales appear to arise out of failures in four processes: prescribing opioid-substitution, supervised dispensing, non-supervised dispensing, and monitoring and communication.

Item Type: Article
Date Type: Publication
Status: Published
Schools: Medicine
Publisher: Wiley
ISSN: 0965-2140
Funders: Primary and Emergency Care Research Centre Wales
Date of First Compliant Deposit: 5 March 2020
Date of Acceptance: 4 March 2020
Last Modified: 04 May 2023 22:40

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