Diamorphine advice issued by National Patient Safety Agency
The safer practice notice was issued to all NHS
organisations recently |
NHS organisations in England and Wales have been advised to review and improve the way that high dose ampoules of morphine and diamorphine injections are prescribed, stored and administered.
The National Patient Safety Agency has issued a safer practice notice
(PDF 280K) containing the following four action points to help protect
patients from potentially fatal mistakes;
· Assess risk and have
procedures for safely
prescribing, labelling,
supplying, storing, preparing and administering
diamorphine and morphine injections
· Review therapeutic
guidelines for the use of diamorphine and morphine injectable products
for patients requiring acute
care, including post-administration observation of patients who have
not previously received opiates
· Update information
concerning the safe use of diamorphine and morphine injectable products
as part of an ongoing programme of training for health care staff on
medication practice
· Ensure that naloxone
injection, an antidote to
opiate-induced respiratory depression, is available in all clinical locations
where diamorphine and morphine injections are stored or administered
The safer practice notice outlines the major risk areas associated with
the high dose ampoules, including similar packaging for different strength
products, storage of high strength ampoules alongside lower strength
products in clinical areas, and insufficient therapeutic training and
understanding by health care staff of the risks involved.
The NPSA adds that implementing the recommendations will also help staff
and organisations meet existing safe practice guidelines on the use of
Controlled Drugs.
The safer practice notice and accompanying patient briefing can be downloaded
as a
PDF (280K). |
Hospital Pharmacist