SafetyShare® newsletter brought to you by the Premier Safety Institute ®
Gina Pugliese, RN, MS, editor
Opioid analgesics and patient safety risks
Examples of opioid analgesics
Opioid-associated adverse drug events (ADEs) and drug diversion of opioids, fed by a growing epidemic of non-medical use, pose a significant threat to
patient safety in the United States.
Opioids associated with significant adverse events, even when used as prescribed
In hospitals, opioid analgesics are one of the most frequent causes of ADEs, responsible for 16 percent of such events in one study. 1 Identified causes of opioid-related ADEs include wrong dose errors, excessive dosing, inadequate
monitoring of patients, interactions with other drugs, and adverse drug reactions or side effects, such as respiratory depression.
Dramatic increase in non-medical use
Non-medical use of these drugs has increased dramatically in recent years, eclipsing use of many other illicit substances, with parallel escalations in
opioid-related overdose and death.3-4 Since 2003, opioids have
been responsible for more deaths by overdose than cocaine and heroin
Drug diversion/stealing poses risks to patients and workers
In addition, drug diversion, that is, stealing or transferring analgesic opioids for non-medical uses, poses a significant risk to individuals, patients,
and health care workers.
Action needed to prevent overuse, misuse and ADEs
Federal and state agencies, as well as professional organizations and physician groups, have called for urgent action to curb the epidemic of opioid misuse
and overuse and reduce the
avoidable errors and adverse drug events associated with inpatient administration of these drugs.
Ten Strategies for Preventing Opioid-Related Adverse Events in Hospitals
- Educate staff at all levels regarding safe opioid use, including the appropriate use of non-narcotic analgesia, the risks associated with opioids, and
assessment for respiratory depression and other adverse drug reactions.
- Ensure the availability of pharmacists or pain management experts to help providers with opioid conversion and dosing.
- Create policies and procedures to ensure ongoing monitoring of patients on opioid therapy.
- Require the use of standardized screening tools to assess the risk of respiratory depression.
- Ensure that oxygen and reversal agents are available wherever opioids are administered.
- Track and investigate opioid-related adverse events.
- Create oversight committees and systems to identify and deter drug diversion by staff.
- Establish clear policies and procedures for evaluating and addressing identified instances of drug diversion.
- Provide written and oral education to patients on opioid therapy or to their caregivers, including risks and side effects, potential for sedation, the
danger of use in combination with alcohol or other sedating drugs, and safe storage at home.
- Use technology to support safe opioid use through decision support and alert systems in the electronic medical record and the use of patient-controlled
analgesia (PCA) devices.
Premier Safety Institute tools, resources and review of opioid risks and prevention strategies
Visit the Premier Safety Institute Website
for more information, tools, and resources on opioid risks and prevention strategies and to download a copy of the white paper
Opioid analgesics: a double threat to patient safety.
Davies EC, Green CF, Taylor S, Williamson PR, Mottram DR, Pirmohamed M. Adverse drug reactions in hospital in-patients: a prospective analysis of
3695 patient-episodes. PLoS One. 2009;4(2):e4439.
Joint Commission. Safe use of opioids in hospitals. Sentinel Event
Substance Abuse and Mental Health Services Administration. Results from the 2010 national survey on drug use and health: summary of national
findings. NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration: 2011.
Centers for Disease Control and Prevention. CDC ground rounds: prescription drug overdoses: a U.S. epidemic.
Morbid Mortal Weekly Rep.
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