New training tool for opioid safety

A new training tool has been developed to address medical errors related to the use of opioids, particularly morphine, in healthcare settings. The initiative, led by a team at the Léon Bérard Cancer Center (CLCC), aims to improve professional practices by identifying and resolving serious unintended events through interactive and engaging training methods.

Medical errors and their causes

These events can include the use of morphine pumps without systematic double verification, leading to dosage errors, as well as poorly performed handovers between treatments that can result in underdosing or overdosing. While such incidents are not frequent, they do occur, prompting the team to adapt their training programs, which take place three times a year, based on reports from caregivers.

Previous training approach and its challenges

Previously, the team had implemented an "error room" equipped with a bed and a PCA pump (Patient Controlled Analgesia), where hidden errors were placed for caregivers to identify. The initiative was successful in 2025, with 130 participants from six professions attending on a single day. However, the second edition in 2026 was less successful, as caregivers struggled to attend due to team absences.

Development of a mobile training cart

This prompted the team to consider a more mobile and engaging approach, leading to the development of a training cart. The cart combines elements of a serious game, incorporating educational and training objectives with playful aspects from video games, board games, or role-playing games. It is designed to be mobile, allowing for more direct engagement with care teams.

Training scenario and its components

The cart includes various accessories, such as a UV lamp and key boxes, costing approximately 300 euros, funded by laboratories within the framework of a pain day organization. The training scenario involves a simulated morphine overdose in a patient. Caregivers, typically a nurse and an assistant nurse, use the cart to trace the chronology of care leading up to the overdose, identifying errors such as unassessed neuropathic pain or handover issues regarding analgesics.

Interactive and realistic training

The scenario includes a doctor's request to stop oral treatment and switch to an intravenous morphine pump, which must be implemented 12 hours later, not immediately. The exercise also raises questions about the side effects of morphine before the overdose and requires caregivers to identify the correct antidote. The training session is fast-paced and interactive, lasting 30 minutes, including a debrief. It is designed to simulate real conditions by incorporating a stopwatch to add a sense of urgency and stress.

Future plans and expansion

The goal is to foster dialogue, complementarity of skills, and collective reflection among caregivers, essential for preventing risks and securing patient care. Currently, the tool is being tested with colleagues and will be presented during a management meeting in November. The team aims to deploy the cart early in 2027, initially in departments that use morphine and opioids most frequently, such as the palliative care unit. The cart is also being considered for adaptation to other themes and potentially other institutions, with ongoing discussions with private nurses to tailor it to their practices.