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Preventing oral opioid agonist therapy (OAT) medication incidents

November 29, 2023
Latest Safety Bulletin from ISMP Canada includes practical advice for pharmacy teams.

The Institute for Safe Medication Practices (ISMP) Canada has released a new report that analyzes Canadian medication incidents involving oral opioid agonist therapy (OAT). Among the quantitative findings in the report—titled Oral Opioid Agonist Therapy: A Multi-Incident Analysis of Reports from Community Pharmacies—was that all reported incidents that led to moderate or severe harm involved methadone. This aligns with the notion that methadone poses an increased risk of harm due to overdose compared to other OAT treatment options such as buprenorphine-naloxone and slow-release oral morphine.

The report includes practical advice and helpful reminders for pharmacy teams who provide OAT services. The advice is broken down into the following three themes:

  • Complex clinical management (including frequent prescriptions and dose adjustments, harmful consequences of missed doses, and directly observed therapy vs. take-home doses),
  • Technical process gaps (including vulnerabilities in product preparation and delayed/omitted documentation), and
  • Security gaps and workplace limitations (including inappropriate patient access and exposure to non-prescribed OAT).

Pharmacy teams who provide OAT services are encouraged to read the report and reflect on opportunities in their own practices to implement policies and procedures to prevent OAT-related practice incidents. For further information about preventing practice incidents and reporting and analyzing them when they occur, refer to ACP’s Drug error management webpage.

Pharmacy teams are reminded that, when providing these services to patients, regulated members must adhere to ACP’s OAT Guidelines.