Patient safety is recognized increasingly as a high priority for all healthcare organizations. Managing medicines safely is central to improving patient safety. Moreover, there is increasing understanding of the frequency and causes of medication incidents, and hence systems may be developed to minimize risks associated with specific classes of drugs. No part of the system is immune to failure and in order to prevent incidents from occurring all stages of the prescribing, storage, dispensing and administration processes must be challenged. Over recent years there has been increasing interest in trying to understand the classes of medicine implicated most frequently and the settings in which these occur in order to reduce the number of medication incidents.

Opioid analgesics are frequently involved in serious medication errors (Smith,2004) and are frequently implicated in serious errors to the NHS Litigation Authority, the Medical Defence Union and the dispensing error analysis scheme. Morphine is one of the most frequently involved drugs in medication errors in other countries too, including the United States and Sweden. In the National Patient Safety Agency (NPSA) report ‘Safety in doses: medication safety incidents in the NHS’ (NPSA, 2007) published in July 2007, opioids were highlighted as being most commonly implicated in medication incidents resulting in severe harm or patient death (see Table 9.1).

Opioids are widely used, in both primary and secondary care, for the management of moderate to severe pain.