Eitel, A.1, Forbes, H. 2, Atkinson, M.3, Spurling, L3. & Johnson, J1,2.

1 School of Pharmacy & Medical Sciences, University of South Australia, 2 SA Pharmacy, SALHN, SA Health, 3Dept of Anaesthesia, SALHN, SA Health, 4 Division of Nursing, SALHN, SA Health


Background: Opioid patches provide non-invasive, continuous delivery of analgesia. Despite their advantages, they come with unique risks and potential for harm. Little is known about the specific incidents occurring related to opioid-patches in hospitalised patients.

Aim: To characterise locally occurring inpatient opioid patch-related incidents to identify targets for quality improvement.

Method: A retrospective review of opioid patch-related incidents reported via the incident reporting system in three public hospitals between 01-04-2016 and 30-06-2018 was conducted. Incidents were categorised by incident type and where in the medication management process the incident originated. Severity of incident outcome was rated using the National Coordinating Council for Medication Error Reporting and Prevention Medication Error Index. Results were summarised using quantitative descriptive statistics.

Results: Forty-seven opioid patch-related incident reports describing 55 discrete incidents were retrieved; 53% pertained to buprenorphine and 47% to fentanyl. Incidents most frequently occurred during the administration phase (56%), followed by the prescribing phase (16%). Most incidents reached the patient (82%), and of these, patient harm was reported in 9% of cases.

‘Failure to remove’ a patch was the most frequently reported single incident type (23% of incidents). However, when pooled, incidents related to omitted analgesia (including ‘displaced’ and ‘inappropriately removed’ patches, and patches ‘charted but not applied’ or ‘not charted’), comprised the greatest proportion of incidents (27%). More than 75% of displaced patches were never recovered.

Conclusion: Many opportunities for pharmacists to promote safe and appropriate opioid-patch use exist. These results will guide development of strategies to optimise safe patch use.

Jacinta Johnson

Dr Jacinta Johnson is a pharmacist teacher-practitioner, currently sharing her time between roles a Lecturer in Pharmacy at the University of South Australia and Senior Pharmacist – Research, within the SA Pharmacy state-wide support service. Within her SA Health role Jacinta is the Executive Officer for the SA Pharmacy Research Leadership Group. In addition, Jacinta is the Vice President of the Society of Hospital Pharmacists of Australia (SHPA), Chairs the SHPA National Residency Advisory Committee and sits on the SHPA Research Specialty Practice Group Leadership Committee.

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