This Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid.
Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
- The initial choice of paracetamol and ibuprofen to control Len’s pain following his fall was in line with national guidance.
- Len’s pain was not effectively controlled on paracetamol and ibuprofen, therefore required review by his GP to address this.
- The choice of a morphine liquid was in line with national guidance and a reduced morphine dose was prescribed in line with recommendations for the older person and Len’s degree of kidney dysfunction.
- Len’s dose of morphine was displayed on the dispensing label attached to the outer box that the morphine was provided in. The label was not seen by Len or his Wife.
- Len and his Wife read the manufacturer’s text on the morphine bottle, which showed the strength of the morphine liquid, and understood this to be the required dose.
- When Len was taken to hospital with difficulty with breathing, he was found to have taken an accidental dose of morphine, he had a chest infection and his Charcot-Marie-Tooth disease may have impacted on his breathing.
HSIB made the following safety observations:
- It may be beneficial if manufacturers of morphine oral solution 10mg in 5ml ensure that any dose measurement aid, if supplied with the medication, is able to measure a full range of possible doses.
- It may be beneficial if professional bodies provided guidance and further support to their members to maximise the learning that can be achieved from safety investigations that may improve patient care.