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

Abstract

Background and 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 the resulting harm relating to this treatment. We aimed to characterize 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 A total of 2284 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 of 127, 72%). Staff-(e.g. slips during task execution, not following protocols) and organization-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were identified for more than half of incidents. 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.

Patients' knowledge, awareness, and attitude regarding patient safety at a teaching hospital, Riyadh, Saudi Arabia

“…It has shown that the principal reasons for these threats were language barriers, the difficulty for patient to communicate with doctors, and the absence of detailed disclosure of both medical conditions and treatment plans. [ 7 ] Also, another study identified failure in communication as a risk factor of harm in delivering opioid substitute in community-based care[ 8 ]…”

Commentary on Gibson et al. (2020): Medications for opioid use disorder– access, retention, and safety

“…The Gibson et al [1] review of safety reports involving methadone or buprenorphine in care programs in England and Wales found that 94% of 2284 incidents resulted in no harm to a patient. Of 129 incidents (6%) that did cause patient harm, 109 were of low harm, 20 were of moderate harm, and 0 were of severe harm.…”

“…As Gibson et al [1] indicate, even if patient safety incidents occur in only a small proportion of cases, increasing access to and retention in MOUD will mean that many more people may be exposed to the potential harms of MOUD‐related incidents. The low‐to‐moderate severity of harms suggests that minimizing them can take place in the context of general care quality improvement.…”

“…Strategies include provider education; support for prescribers (e.g. electronic prescribing systems with safety prompts to highlight patients at risk for overdose); alerts to prescribers on MOUD‐benzodiazepine co‐prescribing; clinical decision support tools; and centralized electronic recording systems [1]. These approaches to increasing access to and retention in MOUD while maintaining the safety of MOUD prescribing and dispensing through monitoring have been taken by the largest health care system and direct provider of substance use disorder treatment in the United States, the Veterans Health Administration (VA) [5], which has 950 community‐based outpatient clinics and 170 medical centers.…”

“…Beyond VA's steps, US efforts to increase MOUD access, retention, and safety include those of the National Institute on Drug Abuse Center for the Clinical Trials Network, which developed recommendations for a clinical decision support system to be incorporated into electronic health records to assist providers to identify and safely manage patients with OUD in general medical settings [7]. As the Gibson et al [1] study highlights, high‐quality OUD care involves not only increasing access and retention but also measuring and minimizing risks of harm in how MOUD is delivered. Safety in delivering MOUD in routine clinical practice needs increased attention from researchers, providers, and management systems as the goals of more patients receiving treatment for a longer duration are achieved.…”