The mis-selection of medicines is one of, if not the largest, new risks introduced with the move from paper to electronic systems for medicines management.  Opioids carry additional risks as the available preparations can vary by up to ten-fold in their concentration; in addition the potential impact of an error in this class of medicines is higher than with many others.     

Reports of errors have identified the format in which the medicines were displayed for selection during the prescribing process as a probable contributory factor. Consequently NHS Connecting for Health (CfH), working closely with the National Patient Safety Agency (NPSA), has published a paper identifying lessons learned that might be applied to reduce the risk of mis-selection of opioid products. It is likely to be of interest both to individuals involved in the design and implementation of ePrescribing systems, and those who use them.  Please see the link below for details.