New Sentinel Event Alert: Safe use of opioids
Although patients might need the strong pain relief that only opioids can provide, a Sentinel Event Alert issued by The Joint Commission urges healthcare providers to take specific steps to prevent serious complications or even deaths from opioid use.
Opioid analgesics rank among the drugs most frequently associated with adverse drug events. Research shows that opioids such as morphine, oxycodone, and methadone can slow breathing to dangerous levels, as well as cause other problems such as dizziness, nausea, and falls. The reasons for such adverse events include dosing errors, improper monitoring of patients, and interactions with other drugs, according to The Joint Commission's Sentinel Event Database. Reports also show that some patients, such as those who have sleep apnea, are obese, or very ill, might be at higher risk for harm from opioids.
"Assessing and managing pain is critical to patients who otherwise would suffer, but avoiding the harm that accompanies the adverse effects of powerful opioid analgesics is equally important," says Mark R. Chassin, MD, FACP, MPP, MPH, president of The Joint Commission. Healthcare providers should educate staff members about the evidence-based actions recommended in the alert, Chassin said. Accidental opioid overuse "is absolutely preventable," he said.
The Joint Commission alert recommends that healthcare organizations take the following actions:
- Implement effective practices, such as monitoring patients who are receiving opioids on an ongoing basis, use pain management specialists or pharmacists to review pain management plans, and track opioid incidents.
- Use available technology to improve prescribing safety of opioids such as creating alerts for dosing limits, using tall man lettering in electronic ordering systems, using a conversion support system to calculate correct dosages, and using patient-controlled analgesia (PCA).
- Provide education and training for staff and patients about the safe use of opioids.
- Use standardized tools to screen patients for risk factors such as oversedation and respiratory depression.
The alert also includes details about respiratory depression risk factors and offers information relevant to opioid risks and safety. The Joint Commission sought input for the alert from experts including the University of Wisconsin Hospital and Clinics, the Hackensack (NJ) University Medical Center, and the University Medical Center in Tucson, AZ. (See story about children who developed serious adverse effects or died after taking codeine for pain relief after tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome, below.)
Resources
To access the Sentinel Event Alert, go to http://bit.ly/OOMevr.
The Food and Drug Administration's Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics is available at http://1.usa.gov/Me9N1A.
Although patients might need the strong pain relief that only opioids can provide, a Sentinel Event Alert issued by The Joint Commission urges healthcare providers to take specific steps to prevent serious complications or even deaths from opioid use.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content