Unsafe & In-efficient use of parenteral opiates & levomepromazine

(procurement, prescribing & administration) for patients with life limiting illness in the community

a. Deemed ‘high alert’ medication, multiple agencies & transitions
b. Limited healthcare professional proficiency with medication & dose ranges, absent or unwieldly processes, sub-optimal communication o Suboptimal symptom control, increased risk patient harm

c. Inefficiency & waste - medicines, healthcare professional time

d. Concerning Medication Safety Incidents in previous 6 months
✓ Medication related events 55% (n=88) community reported incidents via National Incident Management System [NIMS] 2019-22

✓ All Medication incidents denoted a category as per NCC-MERP index

e.  Organisational & reputational damage arising from complaints

f.  Use of QI methodology for problem analysis, measurement, stakeholder engagement & test improvement ideas via PDSA cycles

2. Project Aim

To reduce preventable* medicines related harm** from 20 incidents per year to Zero through safe, timely, co-ordinated prescribing & administration of parenteral opiates & levomepromazine for patients with life limiting illness in receipt of community specialist palliative care in the Mid-west

* Preventable harm associated with prescribing, dispensing or administration errors
** Medicines Related Harm – Category E-I as defined by National Co-ordinating Council Medication Error Reporting & Prevention (NCC-MERP) index

Figures & Tables 

3. HAVE we managed to reduce harm from use of parenteral opiates & levomepromazine in the community ?