Fentanyl patches are an effective pain reliever for the treatment of chronic pain. When not used correctly, such as administering the wrong type of patch or mixing with other high-dose medications, it can lead to serious harm or even death.

At GR Baker Memorial Hospital – a 38-bed acute care centre with 100+ nursing staff in Quesnel, British Columbia – patient safety is a top priority. For the past year, Melody Moore, Clinical Practice Leader of Medicine and Maternity, has been analyzing BC PSLS data to identify patient safety events involving fentanyl patches as a way to educate staff and reduce the occurrence of these events.

“We found that fentanyl-related safety events kept cropping up,” says Melody. “We teamed up with Pharmacy to take a closer look at PSLS data and we could see that staff was having difficulty with how to properly remove fentanyl patches, knowing when to put them on or take them off, and what to do when new medication orders were received.”

During their investigation, Melody and her Pharmacy colleagues discovered that the problem was not unique to GR Baker Memorial and that other facilities in Northern Health were experiencing similar issues. The team recognized an ideal teaching opportunity and moved forward with a plan to educate staff.

“We started with one-on-one education but that got old very quickly,” Melody says. “So we decided to hold a 15-minute in-service at 2pm every afternoon. That way we could explain proper fentanyl patch procedures to the entire group without pointing fingers. This provided a supportive learning environment and the opportunity to share standards for best practice.”

Today, fentanyl patch in-service sessions at GR Baker Memorial are combined with one-on-one education and included in orientations for new staff and graduates, ensuring that all staff receives training. As a result, there have been no further reports of fentanyl patch safety events at the Hospital.

“We believe BC PSLS is best used as a teaching tool,” says Melody. “We feel it’s very important to not penalize staff but rather to teach best practices and the importance of reporting – the reporting piece is important, it’s not squealing, it’s about trying to address problems and improve patient safety.”

An added benefit arising from this initiative is the ongoing collaboration with Pharmacy, which now meets with all new hires to teach Medication Reconciliation – a significant component of Accreditation. With an upwards of 40 orientation days per year, Melody says this teaching is important because it provides new staff with a solid foundation from the beginning and a higher probability that they will want to continue building their careers at GR Baker Memorial.

Congratulations to the team!