The web-site is now in readonly mode. Login and registration are disabled. (28 June 2019)

Victoria Hewitt's design narrative

Cloud created by:

Victoria Hewitt
2 April 2015

Educating GPs about safer opioid prescribing at the end of life

Narrator:   I am a senior palliative care physician, with a special interest in safe medicines management at the end of life.  I'm also a lecturer at the Graduate Medical School, leading a pain management course. Hence, when an educational programme to address some issues of unsafe prescribing practice amongst local GPs was proposed, I was approached to design and lead it.

Situation:  The community palliative care team had identified and reported a number of prescribing errors amongst their patients.  Analysis of these incidents showed that the safe prescribing of strong opioids (such as morphine and oxycodone) for pain control in people in the last few weeks of life was an issue, particularly in kidney failure.  Some strong opioids were more risky than others, particularly those that were injected.  There was no pattern of prescriber, practice or location.  Strong opioids are known to "high risk" drugs and this is monitored nationally (Medicines Safety Thermometer).  The local Clinical Commissioning Group (CCG) agreed that education was required.

Task:  To educate GPs about safer opioid prescribing at end of life, making them aware of pitfalls and enabling them to implement procedures to mitigate these risks. Success was measured by participant feedback from the educational events and from the number of opioid-related drug errors identified.


1) secured dates, times, venue and funding.  Two events were held.  The major obstacle came in securing a venue.  We discovered that the hospice seminar room had been booked extensively by an external team, leaving us limited to Monday afternoons, which is possibly the busiest day of the week for GPs.  We also learnt that the hospice's address on google maps is incorrect, meaning several attendees got lost and turned up late.  We have had to prioritise meeting rooms for palliative care, signpost delegates clearly to the correct postcode and explore the possibility of providing online collaborative learning for GPs in
2) I reviewed national guidance and published literature on opioids, including their side effects and safe prescribing guidelines.
3)  I reflected on medicines management improvement project we had successfully implemented in the hospice.  I used this process-based structure as a framework for small group discussion about the risks GPs and patients face.
4) The GPs were then asked to come up with ideas to reduce these risks from their own practice and referencing national guidelines.
5)  the session ended with each participant writing a pledge to do something differently in their practice as a result of this education.  Pledges (anonymous) were displayed on a "pledge wall", which was photographed and shared on Twitter.


Results:  The sessions evaluated well, with a total of 40 attendees.  Everyone made a pledge and consented to it being shared.  A minority of participants did not like the group work, stating a preference for didactic "talk and chalk" learning.  It's too early to know whether drug errors have reduced and we may never be able to measure exactly how much these sessions have contributed to safer patient care.  However, the CCG has formally commissioned more education, so I interpret that as success.  Unexpected learning came in relation to our system for booking classrooms

Reflections:  These sessions had the potential to be confrontational, as we (te hospice team) had identified an area of inadequate practice in the professional group we were educating.  I had to ensure there wouldn't be an "us and them" hierarchy.  I tried to do this by making it a collaborative effort and it largely worked.  We will have to see if it has contributed to safer care by monitoring error reports.  I would definitely try this approach again rather than the usual large group teaching.  I was also pleased that everyone made a pledge, even if it was from a sense of bemusement rather than genuine commitment.



Extra content

Embedded Content

CompendiumLD Map of Safer Opioids Prescribing Lesson

CompendiumLD Map of Safer Opioids Prescribing Lesson

added by Victoria Hewitt


Catherine Lee
8:36am 6 April 2015

Hi Vicky,

I find this very interesting, particularly the minority resistance to the collaborative approach. I have a similar small-but-significant number of level 1 undergrads who are resistant to this style of learning -it's fascinating that it seems to be conssitent across the board, at any level.  

I wondered about your final comments about 'bemusement rather than genuine commitment' and wondered what they were based on?

I really like the match between activity design and the aim to minimise the opportunity for confrontation. I loved the idea of the plede wall and also felt that your conclusions about effectiveness are well-grounded. 

all best


Victoria Hewitt
9:08am 6 April 2015

Thanks, Catherine.

Perhaps I'm just being cynical about the pledge wall.  Time will tell whether the pledges were carried through, but if nothing else it was a novelty and that may make it stick in the memory.


peter arnold
2:57pm 6 April 2015

hi vicky,

this activity sounds a lot like the case study about communication between parents, gps' and specialists we looked at a few weeks ago. i don't envy you standing up in front of a roup like this...

i think your strategy of group work is a good one, even though some didn't like it. it generally just takes a few people to 'get the ball rolling' before constructive discussion takes place.

i think the chalk and talk method also aids the 'doubters' by enable them to either become arguementative or to totally ignore what you are saying.

the pledge wall gives people the opportunity to add to the discussion, if they disagree or to accept the groups conclusions.


Victoria Hewitt
7:44pm 6 April 2015

Hi Peter,

Certainly Engestrom's article reminded me very much of healthcare quality improvement work such as this.  Good or bad memories... well, I'll not divulge that here!


Robert Lomax
8:41am 15 April 2015

Looks good Vicki! I was relieved to find that everyone can 'STOP' at the end! - hopefully better informed than when they started!


Contribute to the discussion

Please log in to post a comment. Register here if you haven't signed up yet.