R E V I E W S & A N A LY S E S Results of the Opioid Knowledge Assessment from the PA Hospital Engagement Network Adverse Drug Event Collaboration Matthew Grissinger, RPh, FISMP, FASCP INTRODUCTION Manager of Medication Safety Analysis Pennsylvania Patient Safety Authority There are several published studies that have looked into errors related to knowledge deficiencies regarding the use of opioids. For example, analyzed data from the ABSTRACT MEDMARX national medication error reporting database revealed 644 harmful opi- oid errors from 222 facilities.1 Of these, 21% were opioid prescribing errors. Another There are many published studies study looked at opioid errors specifically in cancer pain patients.2 The authors found and reported events that demonstrate that 70% of those with cancer pain had at least one incorrect opioid prescription—and potential gaps in the knowledge regard- in some cases, there were up to seven errors per patient. One of the common errors ing the use of opioids. As a part of the Pennsylvania Hospital Engagement Net- was the use of incorrect dosing intervals. work adverse drug event collaboration To describe the epidemiology of medication prescribing errors averted by pharmacists, sponsored by the Centers for Medicare the clinical staff pharmacists in a 700-bed academic medical center saved all orders that and Medicaid Services, an 11-question contained a prescribing error for a week in early 2002.3 Anti-infective agents, cardio- opioid knowledge assessment tool for vascular agents, and opioid analgesics accounted for 57% of the clinically significant participating hospitals was developed prescribing errors. to assess their practitioners’ current knowledge about the use of opioids. In a pilot study to evaluate the hypotheses that there are differences in pediatric pain The questions covered a variety of issues management knowledge across resident specialties and that questions in the form of associated with the use of opioids, includ- multiple-choice items could detect such differences, fewer than 50% of respondents ing differences between opioid-naïve and were able to correctly convert from one opioid to another (defined as opioid equian- opioid-tolerant patients, indications for algesia).4 In addition, 46% of residents who correctly converted from one opioid to long-acting opioids, and patient-specific another were anesthesiology residents. The authors concluded that this revealed a real conditions that require a lower start- knowledge deficit among pediatric and orthopedic residents in opioid equianalgesia. ing dose of opioids. More than 1,700 Based on these findings, and as a part of the Centers for Medicare and Medicaid Ser- individual practitioners completed the vices (CMS) Partnership for Patients, the Pennsylvania Hospital Engagement Network’s assessment. The lowest-scoring ques- (HEN) adverse drug event collaboration focuses on problems with the use of opioids. tions encompassed topics identifying the As part of the opioid collaboration, the analysts decided to develop an opioid knowl- predictors of respiratory depression in edge assessment tool for participating hospitals to assess their practitioners’ current patients receiving intravenous opioids, defining what constitutes an opioid-tol- baseline knowledge on problematic issues with the use of opioids. erant patient, and choosing medications that could potentiate the effects of an Medication Errors opioid with respect to a patient’s ventila- Opioid drugs are a necessary component of pain management for many patients. tion. Strategies that organizations may When used inappropriately, or in error, they present serious risks that can lead to consider include assessing the organiza- patient harm. An opioid, morphine, was one of six medications or medication classes tion’s need for training based on the on the first Institute for Safe Medication Practices (ISMP) list of high-alert medications analysis of reported adverse events, near published in 1989.5 High-alert medications are defined as drugs that bear a heightened misses, outcome measures, staff obser- risk of causing significant patient harm when they are used in error.6 The current vations, and knowledge assessments. ISMP’s List of High-Alert Medications for acute care hospitals includes opioids as one of This type of analysis may be helpful 22 high-alert drugs or drug classes. in identifying knowledge gaps and in developing improvement strategies to Errors with opioids have led to serious adverse events, ranging from allergic reactions, reduce medication errors associated with failure to control pain, oversedation, respiratory depression, seizures, and death. opioid use. (Pa Patient Saf Advis 2013 According to data from the United States Pharmacopeia MEDMARX program, opi- Mar;10[1]:19-26.) oids, particularly morphine and HYDROmorphone, are still among the most frequent high-alert medications to cause patient harm.7 In 2004, among medication error events Scan this code reported to the Pennsylvania Patient Safety Authority’s Pennsylvania Patient Safety with your mobile Reporting System (PA-PSRS), approximately one out of four reports involved high-alert device’s QR medications. Of those reports, 44% involved opioids, including morphine, HYDRO- reader to access morphone (Dilaudid®), meperidine (Demerol®), and fentaNYL.8 the Authority’s toolkit on this topic. Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 19 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Additional analysis of medication error Prescribing opioids without The purpose of the ADE opioid collabo- and adverse drug reaction events involv- knowledge that an epidural opi- ration is to explore the current trends ing HYDROmorphone reported to the oid had been administered of opioid therapy within organizations, Authority also revealed the following:9 Prescribing doses of opioids too barriers to optimal therapy and safety, — The most common medication high for patients with a history common types of errors that occur with error event types associated with of respiratory conditions (e.g., opioids, and contributing factors that HYDROmorphone were wrong sleep apnea), for patients on lead to patient harm from opioid use. dose/overdosage (16.9%) and wrong concomitant medications with This collaboration includes all care and drug (10.9%). sedative properties, or for elderly procedural areas, as well as practitioners patients who prescribe, dispense, administer, or — A majority of the HYDROmorphone — Patient monitoring problems: monitor patients on opioids. The goal overdoses that occurred during the of the collaboration is to decrease the prescribing node involved orders for Failure to notice respiratory number of harmful events with opioids a wrong dose (79.6%), followed by depression due to insufficient, for participating hospitals (compared with an incorrect frequency (18.5%). improper, or untimely monitor- the participating hospitals' baseline using — Of the reported central nervous ing of patients receiving opiates historical controls). system (CNS) and respiratory adverse drug reaction reports, 65% appear Proposed Intervention Hospitals that signed up to participate to have been preventable adverse On December 14, 2011, CMS announced in this collaboration were asked to be drug events (ADEs) (i.e., medication the award of $218 million to 26 state, involved in errors) in which patients received regional, and national hospital system — developing a multidisciplinary task a dose in excess of what would be organizations to serve as HENs. The force team; needed to resolve pain symptoms Department of Health and Human Ser- — asking staff to complete baseline (e.g., greater than a 1 mg dose for vices sponsored the contract, which is and follow-up opioid knowledge an opioid-naïve adult patient) or part of the public-private Partnership for assessments; in which HYDROmorphone was Patients. This initiative was started to help — completing baseline and follow-up prescribed and administered with keep patients from being harmed while in opioid organizational assessments; other medications that would lead the hospital and heal without complica- tions once they are discharged.11 — collecting outcome measures, specifi- to additive sedative effects (e.g., cally naloxone use for patients on orders for both morphine and The Hospital and Healthsystem Associa- opioids and rapid response team HYDROmorphone). tion of Pennsylvania (HAP) is the only calls primarily due to opioids; Additional examples of factors associated Pennsylvania-based organization that — gathering and reviewing documents with medication errors involving opioids serves as a HEN as part of the Partner- related to established process mea- that have been published by ISMP or ship for Patients initiative.12 According to sures with the use of opioids; learned from root-cause analyses of actual HAP, it will be under a two-year contract errors include the following:10 with its partners (the Authority, the — submitting program feedback; and Health Care Improvement Foundation, — participating in webinars and confer- — Dosing errors in opioid-naïve Quality Insights of Pennsylvania, and ence calls. patients: the Pennsylvania Health Care Quality Prescribing initial doses too high METHODS Alliance) to implement strategies to sup- for opioid-naïve patients, espe- port Pennsylvania hospitals in achieving As a part of the collaboration, the Author- cially with HYDROmorphone Partnership for Patients’ goals of reducing ity partnered with the Pennsylvania and fentaNYL transdermal preventable hospital-acquired conditions, Medical Society to develop a clinician systems readmissions, and complications during knowledge assessment tool for opioids for Unfamiliarity with proper oral hospitalization. There are 10 core areas of prescribers, pharmacists, and nurses. The (PO)-to-intravenous (IV) dose focus that are a part of the overall project, assessment consisted of two demographic conversions for some opioids including ADEs. In Pennsylvania, the questions, the practitioner’s position and Prescribing short-acting opioids ADE collaboration specifically addresses how long he or she has worked in the without knowledge that long- the safe use of opioids. facility, followed by 11 multiple-choice acting morphine (DepoDur®) assessment questions. The questions had been administered Page 20 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority covered a variety of problematic issues Figure. Percentage of Completed Knowledge Assessments by Type of Practitioner associated with the use of opioids, includ- (N = 1,758) ing the following: Attending/staff physician — Differences between “opioid naïve” 5.9% and “opioid tolerant,” and what con- 17.8% Resident physician/ stitutes or makes a patient “opioid physician in training 15.7% tolerant” Physician assistant/ — Indications for long-acting opioids nurse practitioner (who and/or when they should be 8.9% prescribed) Registered nurse 3.9% — Comparative dosing between two dif- ferent opioids, particularly morphine Pharmacist and HYDROmorphone — Patient-specific conditions that require 47.8% Other MS13059 a lower starting dose of opioids — The impact of concomitant medica- tions in combination with opioids — Monitoring the effects of opioids The multiple-choice assessment was built macists (15.7%, n = 276); resident Opioid-induced respiratory depression and conducted in a web-based survey tool, physicians/physicians in training (8.9%, can be defined as a decrease in the effec- which was distributed by e-mail. Users n = 157); practitioners who selected tiveness of an individual’s ventilatory were required to enter an organization- “other” (5.9%, n = 104); and physician function after opioid administration.14 specific four-digit code to associate results assistants/nurse practitioners (3.9%, Sedation generally precedes significant with specific facilities. A paper version n = 68). Practitioners who selected “other” respiratory depression.15,16 Opioid-induced was also used by organizations to capture were predominantly certified registered sedation occurs on a continuum ranging responses from practitioners who were nurse anesthetists (46.1%, n = 48). from full consciousness to complete loss unable to respond by e-mail. This tool of consciousness and respiratory arrest. The lowest-scoring questions in the assess- was released on June 5, 2012, and the last Unintended advancing sedation occurs at ment included topics addressing the day of data submission was August 26, increasingly higher levels along the contin- following: 2012. (The tool will be available for use at uum of sedation, impairing both arousal http://patientsafetyauthority.org/ — Identifying the most important pre- mechanisms and content processing. EducationalTools/PatientSafetyTools/ dictor of respiratory depression in Pages/home.aspx.) patients receiving IV opioids Acute pain appears to stimulate respi- — Defining what constitutes an opioid- ration and antagonize the respiratory RESULTS tolerant patient depressant effects of opioids.17 While pain can antagonize opioid-induced respira- — Choosing which medication could Practitioner Characteristics tory depression, sleep can intensify the potentiate the effects of HYDRO- depressant effects of opioids. In addition, Practitioners from 24 of the 29 (83%) hos- morphone on ventilation as carbon dioxide levels increase due to pitals that signed up for the collaboration Predictor of Opioid-Induced respiratory depression, patients exhibit participated in the assessment. More than a reduction in overall level of conscious- 2,000 practitioners started the assessment, Respiratory Depression ness that is additive to the direct sedative of which 1,758 individuals (79%) com- Sedation is a common and expected effects of opioids. Critical incidents from pleted the assessment (see Figure). adverse effect of opioids, particularly at the opioid-induced respiratory depression Overall, more registered nurses (47.8%, start of therapy and generally during the appear to be more common in the hours n = 840) completed the opioid knowledge first 24 hours of opioid therapy, as well as from midnight to 6 a.m.17 Depression assessment than any other type of practi- with increases in opioid dose.13 Although of level of consciousness is an extremely tioner. Other practitioners included (in respiratory depression is less common than useful guide to observing clinical effect decreasing order of participation): attending/ sedation, it is frequently the most serious staff physicians (17.8%, n = 313); phar- of the opioid-induced adverse effects. (continued on page 25) Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 21 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table. Results of the Opioid Knowledge Assessment by Individual Question and Practitioner Type CIAN/PHYSICIAN IN TANT/NURSE PRAC- ATTENDING/STAFF PHYSICIAN ASSIS- RESIDENT PHYSI- OVERALL NO. OF PHARMACIST (%) PHYSICIAN (%) TRAINING (%) TITIONER (%) OVERALL (%) REGISTERED RESPONSES QUESTION NURSE (%) OTHER (%) ANSWER Patients who are 2,024 Taking acetaminophen 300 mg 6.4 6.3 6.3 3.9 7.5 3.7 5.8 considered opioid with codeine 30 mg, up to 5 tolerant are those who doses a week have been: Taking oxyCODONE 10 mg 1.4 1.4 3.4 0.0 1.1 1.7 1.7 with acetaminophen 325 mg 4 times daily for 5 days Taking oxyCODONE 10 mg 29.1 34.2 24.0 32.5 25.5 40.5 20.7 with acetaminophen 325 mg 4 times daily for 14 days Taking extended-release 10.2 8.8 11.4 14.3 8.5 16.3 9.1 morphine 15 mg twice daily for 1 week All of the above 52.9 49.3 54.9 49.4 57.4 37.8 62.8 The most important 2,023 Respiratory rate 49.1 36.8 45.7 50.6 49.0 62.9 56.2 predictor of respiratory depression in patients Patient-reported pain 0.6 1.1 0.6 1.3 0.3 0.7 0.8 receiving intravenous (IV) intensity opioid analgesics in the Sedation level 22.4 33.0 30.9 19.5 20.1 16.0 15.7 hospital setting is: Blood pressure 0.3 0.0 0.0 1.3 0.2 1.0 0.0 All of the above 27.6 29.1 22.9 27.3 30.4 19.4 27.3 Which of the following 2,024 They are intended for use for 6.6 4.0 4.0 3.9 10.1 0.0 6.6 statements about long- pain on an as-needed basis. acting opioids is true? They are indicated for pain in 10.3 4.5 17.1 7.8 11.3 6.5 20.5 the immediate postoperative period (12 to 24 hours following surgery). They are indicated for pain 13.5 11.6 10.3 13.0 14.5 12.6 18.0 during the postoperative period, if the pain is not expected to persist for an extended period of time. They are only indicated if the 56.5 71.6 58.3 71.4 46.4 78.6 31.1 patient is opioid tolerant and has already been receiving the drug prior to surgery. All of the above 13.0 8.2 10.3 3.9 17.7 2.4 23.8 Which of the following 1,898 0.4 mg 67.2 70.1 80.6 73.2 55.8 92.6 66.7 best represents the equianalgesic dose of IV 0.8 mg 8.6 12.7 6.7 9.9 9.1 2.8 9.0 HYDROmorphone to IV 1 mg 19.2 14.2 10.3 14.1 28.0 3.5 17.1 morphine 2 mg? 2 mg 5.0 3.0 2.4 2.8 7.2 1.1 7.2 Page 22 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority Table. Results of the Opioid Knowledge Assessment by Individual Question and Practitioner Type (continued) CIAN/PHYSICIAN IN TANT/NURSE PRAC- ATTENDING/STAFF PHYSICIAN ASSIS- RESIDENT PHYSI- OVERALL NO. OF PHARMACIST (%) PHYSICIAN (%) TRAINING (%) TITIONER (%) OVERALL (%) REGISTERED RESPONSES QUESTION NURSE (%) OTHER (%) ANSWER Which patient-specific 1,899 Hypertension 0.2 0.3 0.0 0.0 0.0 0.0 1.8 parameters might cause you to consider reducing Sedation following 6.6 7.3 10.9 5.6 5.7 7.7 4.5 the initial dose of administration of morphine HYDROmorphone? A history of obstructive sleep 10.4 4.5 6.1 2.8 11.2 19.0 9.9 apnea Hypertension and a history of 1.9 3.0 1.8 1.4 1.4 2.1 3.6 obstructive sleep apnea Sedation following 65.9 71.9 70.9 66.2 66.8 54.9 61.3 administration of morphine and a history of obstructive sleep apnea Hypertension, sedation 15.0 13.0 10.3 23.9 14.9 16.2 18.9 following administration of morphine, and a history of obstructive sleep apnea The best choice to 1,832 Ask the nurse to provide 63.0 71.7 64.4 58.0 63.0 49.1 73.6 manage this patient’s reassurance to the patient pain and restlessness and continue to monitor is to: him for signs of increased sedation and respiratory depression Administer diphenhydrAMINE 29.4 20.2 28.8 34.8 29.7 42.3 19.1 25 mg proper oral (PO) Administer diazepam 10 mg 4.1 3.4 4.4 4.3 4.8 2.2 4.5 PO Administer midazolam 3.5 4.7 2.5 2.9 2.5 6.5 2.7 2 mg IV Which of the following 1,831 Patient-reported pain 0.5 0.9 0.6 0.0 0.2 0.7 1.8 patient-specific intensity parameters is/are the most important Level of sedation 2.6 5.0 3.8 1.4 2.5 0.4 1.8 to monitor in Adequacy of ventilation 2.7 3.1 3.8 2.9 2.5 0.4 7.3 patients receiving IV HYDROmorphone? Respiratory rate 6.2 4.3 5.6 1.4 7.9 4.7 6.4 Patient-reported pain 11.7 9.3 11.3 4.3 10.7 19.0 13.6 intensity and respiratory rate Patient-reported pain 76.2 77.3 75.0 89.9 76.3 74.9 69.1 intensity, level of sedation, and adequacy of ventilation Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 23 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table. Results of the Opioid Knowledge Assessment by Individual Question and Practitioner Type (continued) CIAN/PHYSICIAN IN TANT/NURSE PRAC- ATTENDING/STAFF PHYSICIAN ASSIS- RESIDENT PHYSI- OVERALL NO. OF PHARMACIST (%) PHYSICIAN (%) TRAINING (%) TITIONER (%) OVERALL (%) REGISTERED RESPONSES QUESTION NURSE (%) OTHER (%) ANSWER Which of the following 1,789 The dose is appropriate since 11.6 7.3 9.4 7.2 15.2 7.6 11.3 statements is correct the patient has an insignifi- in regard to the cant past medical history. HYDROmorphone 1 mg order? The dose is too high because 77.4 85.2 79.9 85.5 70.5 87.8 74.5 the patient is opioid naïve and over 80 years old. The dose is too low because 4.7 4.4 5.0 2.9 5.8 1.4 5.7 the patient’s chronic medica- tions will lead to rapid me- tabolism of HYDROmorphone. The dose is too low based on 6.3 3.2 5.7 4.3 8.5 3.2 8.5 her elevated body mass index. Which of the following 1,788 Atorvastatin 0.9 0.3 0.6 1.4 1.0 0.7 1.9 agent(s) can potentiate the effects of FLUoxetine 2.6 2.5 3.8 1.4 2.7 2.9 0.9 HYDROmorphone on ALPRAZolam 51.5 47.6 54.1 58.0 49.9 59.6 45.8 ventilation? Atorvastatin and ALPRAZolam 5.2 6.0 6.9 2.9 5.1 1.8 11.2 FLUoxetine and ALPRAZolam 39.8 43.5 34.6 36.2 41.2 35.0 40.2 What would be the best 1,759 Order a second dose of IV 3.5 3.2 5.1 7.4 3.7 1.8 2.9 option to control this HYDROmorphone 1 mg patient’s pain? Assess sedation level, then 60.4 72.2 61.8 60.3 54.0 68.8 52.9 continue titration of IV HYDROmorphone 0.2 mg to 0.4 mg every 10 minutes Order a nonopioid pain 34.8 24.3 31.8 32.4 41.0 28.3 40.4 reliever until the initial dose HYDROmorphone starts to have an effect Order a dose of meperidine 1.2 0.3 1.3 0.0 1.3 1.1 3.8 25 mg IV Which patient-specific 1,758 Hypertension 0.6 0.0 1.3 0.0 0.6 1.1 1.0 parameter(s) might cause you to consider Patient’s age 10.1 7.3 8.3 7.4 8.9 17.4 13.5 reducing the subsequent Coronary artery disease 0.8 0.3 0.0 0.0 1.1 0.7 1.9 dose of opioid? Sedation following the initial 70.6 78.9 79.6 72.1 70.7 60.5 56.7 dose of HYDROmorphone Patient’s age and coronary 17.9 13.4 10.8 20.6 18.7 20.3 26.9 artery disease Note: Percentages for individual questions are added vertically and reflect each practitioner type’s responses for each answer choice; correct answer choices are shaded gray. Case examples were included for some questions in the original assessment but are not provided in this table. Page 24 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority (continued from page 21) This definition of opioid tolerance that is Safety Knowledge Exchange (PassKey) site. endorsed by the Food and Drug Admin- In addition, the results of the knowledge in patients receiving opioids. Respiratory istration (FDA) is also found in many of self-assessment tool have helped identify depression is almost always preceded by the new Risk Evaluation and Mitigation statewide knowledge gaps that need to be sedation or clouded sensorium.18 Strategy documents and FDA-approved addressed through education or other tech- Medication Guides for new opioids.22 nical assistance. The Authority will work The second question posed on the assess- The first question posed on the assessment with the Pennsylvania Medical Society to ment (see Table) asked practitioners to (see Table) asked practitioners to identify develop tools on opioids to address these select the most important predictor of the order(s) that would make a patient gaps. Collaboration will also continue with respiratory depression in patients receiving tolerant to opioids. Only one of the four the Pennsylvania Society of Anesthesiolo- IV opioids. Participants could select respi- proposed orders was correct. Overall, gists to continue to enhance the role of the ratory rate, patient-reported pain intensity, 29.1% of all respondents answered the anesthesia department in pain manage- sedation level, blood pressure, or all of the question correctly; 34.2% of physicians, ment overall in participating facilities. above. Overall, 22.4% of all respondents answered the question correctly; 33.0% of 25.5% of nurses, and 40.5% of phar- The Authority intends to repeat this opi- physicians, 20.1% of nurses, and 16.0% macists answered correctly. In addition, oid knowledge assessment to determine of pharmacists answered correctly. almost 53% of all respondents answered if improvements have been made within “all of the above”; 49.3% of physicians, organizations in regard to use of opioids. Opioid Tolerance 57.4% of nurses, and 37.8% of pharmacists thought that all of the listed orders would CONCLUSION Although opioids are often titrated to the render a patient to be opioid tolerant. effective dose to avoid dose-dependent The results of the knowledge assessment adverse effects, the appropriate starting supported the Authority’s perception doses or the use of potent and/or long- Medications That Potentiate the that Pennsylvania hospitals may have acting dosage forms for chronic pain Effects of Opioids on Ventilation underestimated or were unaware of the depend on whether patients are opioid Various patients are at higher risk for degree of opioid knowledge deficit among tolerant or opioid naïve.19 adverse events from opioid use, including practitioners. The knowledge assessment patients with sleep apnea, patients who has identified basic knowledge gaps by “Opioid naïve” implies patients are not are morbidly obese, and patients who con- practitioners, which will hopefully spur chronically receiving opioids on a routine currently receive other drugs that are CNS organizations to address these gaps and basis. “Opioid tolerant” implies patients and respiratory depressants. This includes possibly assess staff knowledge about are chronically receiving opioids on a daily patients receiving other sedating drugs, other high-alert medications. Based on basis. Opioid-tolerant patients, as defined such as benzodiazepines, antihistamines, the results of the opioid knowledge assess- in the fentaNYL transdermal patch offi- diphenhydrAMINE, sedatives, or other ment, organizations should consider both cial labeling, are those who have been CNS depressants.23 One study found that educating and assessing the understand- taking, for a week or longer, at least 60 mg most ADEs were due to drug-drug interac- ing of staff that care for patients receiving of oral morphine daily, at least 30 mg of tions, most commonly involving opioids, opioids about the following:14,24 oral oxyCODONE daily, at least 8 mg of benzodiazepines, or cardiac medications.24 Potential effect of opioid therapy on oral HYDROmorphone daily, or an equi- — analgesic dose of another opioid.20 This is The ninth question posed on the assess- sedation and respiratory depression the lowest daily dose of opioid taken over ment (see Table) asked practitioners to — Differences between opioid-naïve a week that a patient must be receiving in identify which medications could poten- and opioid-tolerant patients, and order to be prescribed the lowest dose of tiate the effects of HYDROmorphone what constitutes or makes a patient fentaNYL transdermal systems. Therefore, on ventilation. Overall, only 51.5% of opioid tolerant fentaNYL transdermal systems should all respondents answered the question — Indications for long-acting opioids only be used in patients who are already correctly; 47.6% of physicians, 49.9% (who and/or when should they be receiving opioid therapy and who have of nurses, and 59.6% of pharmacists prescribed) demonstrated tolerance.19 answered correctly. — Equianalgesic dosing between opi- Giving potent, long-acting opioids like a oids, IV to PO as well as between fentaNYL transdermal system to opioid- NEXT STEPS two different opioids naïve patients has resulted in deaths.21 Facility representatives from participat- — Patient-specific conditions that Thus, most long-acting opioids such as ing organizations were provided with require a lower starting dose of fentaNYL transdermal system should not facility-specific assessment results on the opioids be used for acute pain. Authority’s password-protected Patient Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 25 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S — The impact of concomitant medica- how to recognize advancing sedation, and the analysis of reported adverse events, tions in combination with opioids the importance of making timely adjust- near misses, outcome measures, staff — Technological and clinical ments to the plan of care based on the observations, and knowledge assessments. monitoring patient’s risk. This analysis may be helpful in identifying Staff training can emphasize how to In addition, it is important to assess the knowledge gaps and in developing improve- assess patients for adverse drug reactions, organization’s need for training based on ment strategies to reduce recurrences. NOTES 1. Dy SM, Shore AD, Hicks RW, et al. Medi- 10. 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Am J Health Syst Pharm 2012 Feb imental pain stimulates respiration and 1;69(3):221-7. Page 26 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 1—March 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. 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