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  • Patient safety in NHS Dorset: Summary of a recent meeting held on the safety improvement programme to reduce harm from opiate drugs

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    Sarah Kay and Jaydee Swarbrick are involved in the Patient Safety in Primary Care Project in Dorset. In this blog, they summarise a recent event they held to share learning from medicines incidents.


    Each NHS Trust and local pharmacies in Dorset have been promoting awareness and providing updates for staff and patients on medications without harm and medicines safety following World Patient Safety Day in September. On Monday 17 October we held a face-to-face event to share learning from medicines incidents and to specifically focus on the safety improvement programme to reduce harm from opiate drugs in our communities. This provided an excellent opportunity to network with other healthcare professionals.

    Speakers on the day were:

    • Head of Medicines Improvement at NHS Dorset who set the scene for the morning with facts and figures for discussion.
    • Clinical Lead for the Wessex Academic Health Science Network Polypharmacy programme provided an update on the wider safety improvement work.
    • Patient Safety Specialist with NHS Dorset presented a patient story of a person that died following accidental fatal intoxication with liquid morphine.
    • Deputy Chief Pharmacist at Dorset County Hospital (DCH) and long serving Medicines Safety officer in Dorset shared the improvement work that has taken place in DCH in relation to opiate prescribing on discharge. 
    • Dr Sarah Kay, GP lead for Patient Safety with NHS Dorset, concluded the morning with a facilitated discussion session to share best practice and consider how organisations can work together to improve medicines safety.

    Attendees included Primary Care Network (PCN) pharmacists, hospital trust pharmacists, NHSD patient safety teams, medicines optimisation team, primary care team, AHSNs.

    In Dorset we prescribe almost double the volume of liquid opioids to patients in our hospitals when compared with others in our region. This increases the risk of prolonged prescribing in primary care, which can lead to long-term tolerance and dependency, and contributes to nearly 700 patients requesting multiple liquid opioid prescriptions each month for chronic non-cancer pain. This prescribing is having a disproportionate impact on women between 40 and 60 years of age and in more deprived areas of our county. 

     At the event, we heard from some acute trusts and PCN colleagues who are having success in reducing opiate usage and promoting safe pain management strategies for people, as well as from the Wessex AHSN who can support ongoing improvement programmes. The morning was compered by NHS Dorset Patient Safety Partner (volunteer lay role) Simon Wraw who ensured the patient perspective was part of our discussions.

    The opportunity to meet face to face with colleagues was really valuable, as well as making new counterpart connections for each professional group. Feedback from attendees was positive and we hope to run a similar event in the future with a different topic focus.

    On the topic of networking, we have also contributed to the setup of the NHSE South West GP Quality Network. A scoping meeting was held in October to co-produce a plan for the network with participants.

    We hope to build the network, so if you work in any patient safety role across the South West and have an interest in general practice and connecting with colleagues to share good ideas and troubleshoot problems together please get in touch.

    The next network meeting will be 22 February 2023. Please email england.swqualityhub@nhs.net for an invite.

    Further reading

    See our recent Patient Safety Spotlight interview with Sarah and Jaydee.

    About the Author

    Sarah Kay is a portfolio General Practitioner based in West Dorset with her family. She has experience in leadership and management, quality improvement and assurance, and GP education. Her clinical work is as a locum GP and she holds a variety of other roles.

    As a Registered Nurse for more than 30 years, Jaydee Swarbrick has been involved in service and quality improvement projects throughout her career with the aim to enhance patient experience and outcomes. Since appointment to the Patient Safety role in March 2017, Jaydee has worked with local system partners to take a collaborative approach to Patient Safety in Dorset embedding partnership working in the Integrated Care System.

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