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105 Inappropriate use of naloxone in a hospital setting compromising patient safety: a quality improvement project
  1. Maria Mandel,
  2. Jennifer Palfrey and
  3. Ruth Caulkin
  1. Chelsea and Westminster Hospital


Background Life threatening opioid toxicity is a rare but recognised complication of opioid use. In 2014, NHS England released a patient safety alert on inappropriate prescribing of naloxone in patients with chronic opioid use, citing 2 fatal cases. A retrospective audit (2017) of naloxone use in an acute London hospital demonstrated that 90% (18/20) of administrations did not meet recommended standards. This prompted a quality improvement project to improve practice.

Methods A trust guideline was developed using the Palliative Care Formulary and UK Medicines Information naloxone evidence review. This was disseminated through education sessions and email updates. An alert was created on the trust electronic prescribing system. Following this, repeat data was collected retrospectively over 3 months for all adult hospital inpatients (excluding ITU and ED) administered naloxone. Electronic clinical notes were reviewed for: reason for naloxone use, respiratory rate, oxygen saturation, level of consciousness and dose given.

Results Repeat audit (2019) demonstrated 3 administrations of naloxone, of which 2 did not meet the guideline standard - an 89% reduction in inappropriate administrations of naloxone compared to baseline. The dose which was appropriately administered was also of the recommended dose.

Conclusion/Discussion There has been a marked decrease in inappropriate administrations of naloxone in patients with chronic opioid use since the intervention. However, continued work is needed as reduced conscious level often triggered naloxone use despite absence of respiratory depression or hypoxia.

Recommendations Continued dissemination of the guideline, particularly with rotation of staff.

Ensure that the prescribing alert is maintained on future prescribing systems.

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