Vulnerabilities in the Delivery of Opioid Agonist Therapy Revealed in Multi-Incident Analysis
As healthcare providers navigate the complexities of opioid agonist therapy (OAT), a first-line pharmacological treatment for individuals with moderate to severe opioid use disorder, the Institute for Safe Medication Practices (ISMP Canada) sheds light on critical safety concerns. OAT, encompassing medications like buprenorphine/naloxone, methadone, and slow-release oral morphine, plays a pivotal role in managing opioid use disorder. However, a recent multi-incident analysis of medication incidents spanning from April 1, 2020, to March 31, 2023, exposes vulnerabilities in the delivery of oral OAT.
Analyzing 1169 incidents extracted from the National Incident Data Repository for Community Pharmacies, the ISMP report outlines the prevalence of OAT-related incidents. Methadone, a high-alert product, is implicated in most incidents, aligning with its recognized elevated risk of harm. While 92% of incidents were reported as near misses or causing no harm, the remaining 8% involved mild to severe harm, all attributed to methadone.
The multi-incident analysis identified three main themes:
Complex Clinical Management:
- Frequent prescriptions and dose adjustments pose challenges, with errors resulting from misinterpretation of regimen changes.
- Harmful consequences of missed doses underscore the need for meticulous documentation and communication.
- Challenges in managing directly observed therapy versus carries contribute to errors in the number of dispensed doses.
Technical Process Gaps:
- Lack of patient identification, contributing to wrong doses being selected.
- Vulnerabilities in product preparation, emphasizing the importance of independent double checks.
- Delayed/omitted documentation and the need for enhanced documentation protocols.
Security Gaps and Workspace Limitations:
- Poorly designed dispensing processes, unsecure storage, and high workload contribute to incidents of patients inappropriately accessing OAT medications.
- Exposure to nonprescribed OAT due to workspace clutter and label mix-ups.
Recommendations:
The ISMP report concludes with recommendations for community-based healthcare teams, emphasizing the importance of rigorous identity checks, enhanced documentation, and securing OAT medications to prevent unauthorized access. The analysis serves as a crucial learning opportunity for healthcare professionals involved in OAT delivery, fostering continuous quality improvement.
Click here for the full ISMP bulletin.
Consultation Notice for CPhM Bylaws
The College of Pharmacists of Manitoba (CPhM) invites you to participate in shaping the future of pharmacy regulation in Manitoba. As part of CPhM’s commitment to transparency and accountability, the CPhM Council is initiating a consultation on proposed bylaws revisions.
In 2020, CPhM Council embarked on comprehensive review of the governance framework, with a goal of modernizing CPhM’s approach, focusing on increased transparency, accountability, and the best interests of the public. After a rigorous initial review, the Governance Committee has worked closely with Council to refine and modernize the bylaws.
Key Amendments
The proposed changes encompass several pivotal areas of our governance structure, including:
- Reduction in Council Members: Streamlining the number of Council members to promote more effective decision-making and governance.
- Adjustments to Terms of Office: Implementation of staggered terms of office, enhancing succession planning for a more seamless transition.
- Term Limits: The introduction of term limits ensures that fresh perspectives are continually infused into the Council’s work, providing valuable continuity.
- Removal of Immediate Past President Position: This revision acknowledges the evolving needs of the organization, leading to the discontinuation of this position.
Your Voice Matters
As part of this process, we want to hear from you. Your feedback is invaluable in shaping the direction of CPhM governance. Council has approved a 45-day consultation period, giving you the opportunity to provide your insights.
How to Get Involved:
- Learn More: Dive into a wealth of comprehensive information about the consultation, including in-depth documents and the rationale behind the proposed changes, available on our dedicated Consultation webpage.
- Provide Feedback: Actively participate in the consultation by sharing your feedback and comments via email to feedback@cphm.ca before December 22, 2023.
- Join the Virtual Town Hall: After the consultation period, CPhM will host a virtual town hall where Council will present highlights of the draft bylaws and take questions from attendees.
Learn More: For further details and access to related materials, please visit the Consultation page.
Register Now: Upcoming 5th Annual Medical Examiner Professional Development Live Webinar
The College of Pharmacists of Manitoba (CPhM) would like to remind you of the upcoming fifth annual Medical Examiner professional development live webinar titled Engaging Patients with Care: Tapering, Brief Interventions, and Substance Use Insights. Join us on November 28, as we explore two presentations: Tapering 101 and Strategies to Engage Individuals in Conversations About Substance Use.
When: Tuesday November 28, 2023, 6:00 p.m.
Registration Link:
https://us02web.zoom.us/webinar/register/7416996398886/WN_Ox1nhym3TmmjIHbMdFRz2g
Learning Objectives:
The webinar consists of two key presentations. The first part focuses on tapering opioids and benzodiazepines, covering the reasons, motivations, and target populations for tapering, comparing different approaches, and discussing withdrawal treatments.
The second presentation emphasizes core principles in patient interactions, including brief interventions and the integration of motivational interviewing skills. Attendees will learn how to initiate conversations, provide constructive feedback, enhance motivation, and effectively negotiate and advise. Additionally, the presentation will provide an overview of mental health and addiction resources and services.
Meet Our Expert Speakers:
- Karin Ens, BSc(Pharm), MSc, EPPh: Karin is a clinical pharmacist based in Winnipeg with an extended practice license in a multi-disciplinary primary care clinic.
- Lori Nicholson RN, BN: Lori is a Clinical Specialist for Shared Health, Mental Health, and Addictions, providing support and education to healthcare service providers across Manitoba.
Don’t miss this opportunity to expand your knowledge and enhance your patient care skills. Join us for this virtual event on November 28 at 6:00 p.m.
Accreditation: Pending
CPhM Career Opportunity – Complaints Investigator
The College of Pharmacists of Manitoba (CPhM) is presently in search of a Complaints Investigator to conduct investigations related to complaints of alleged unprofessional conduct and professional incompetence in accordance with The Pharmaceutical Act (the Act), Pharmaceutical Regulation (Regulation) and all other applicable legislation governing the practice of pharmacy.
The successful candidate will oversee the resolution of informal concerns, carry out all necessary tasks related to investigating and reporting on formal complaint assignments and contribute to the discipline process as required.
This is a full-time permanent position, Monday to Friday, based on a 37.5 – hour workweek.
For a complete description of the duties, qualifications, and required attributes for this position, and to apply, view the on-line posting:
- Career Page: https://www.fitzii.com/apply/82040?s=fc
- Indeed: https://www.fitzii.com/apply/82040?s=in
- LinkedIn: https://www.fitzii.com/apply/82040?s=li
Applications will be reviewed from all sources as received until the position is filled.
CPhM values diversity and inclusion and encourages all qualified people to apply.
Upcoming Events and Professional Development Opportunities
Lessons from Complaints: A Series on Injection-Related Best Practices
- Part 1: Best Practices Review for Pharmacists
Click here to view the recording.
0.75 accredited CEU - Part 2: Trends in Injection-Related Complaints
Click here to view the recording.
Managing Drug Shortages in Pediatric Patients
Can be claimed as 0.75 accredited CEUs
Recording available here.