R E V I E W S & A N A LY S E S Results of the PA-HEN Organization Assessment of Safe Practices for a Class of High-Alert Medications Matthew Grissinger, RPh, FISMP, FASCP INTRODUCTION Manager, Medication Safety Analysis Pennsylvania Patient Safety Authority Proactively assessing practices and processes in the medication-use system, especially Rebecca L. Lamis, PharmD, FISMP those involving high-alert medications such as anticoagulants, insulin, or opioids, can Medication Safety Analyst provide hospitals with valuable information about the weaknesses that exist within Institute for Safe Medication Practices their systems before harmful events occur. As the harm from errors involving high-alert medications can be potentially devastating, proactively identifying the risks associated ABSTRACT with opioid use should be considered a priority by hospitals. Proactively assessing practices and Pennsylvania Patient Safety Authority analysts developed an assessment tool for the processes that involve high-alert medi- Pennsylvania Hospital Engagement Network (PA-HEN) adverse drug event (ADE) opi- cations such as anticoagulants, insulin, oid project to help participating hospitals assess the safety of practices in their facility, and opioids can enable hospitals to identify opportunities for improvement, and compare their experiences with the aggre- identify the weaknesses that exist within gate results of other participating hospitals in Pennsylvania. The aggregate findings also their medication-use systems. As a part may be used to develop an action plan for the PA-HEN collaboration for implementing of the Pennsylvania Hospital Engage- recommended error reduction strategies in order to assist hospitals in enhancing safety ment Network adverse drug event with this class of medications. collaboration, a 45-item organization This article provides a descriptive analysis of the key findings from the assessment, with assessment tool was developed to a focus on areas where significant improvements in opioid medication safety are needed. assess the safety of opioid practices in hospitals, identify opportunities for METHODS improvement, and enable participating hospitals to compare their results with Hospital Team the aggregate results of all participat- Since medication use is a complex, interdisciplinary process, the value and accuracy of ing hospitals in Pennsylvania. Almost the assessment would be significantly reduced if it was completed by a single discipline. 60% (n = 17) of participating hospitals Therefore, hospitals were asked to establish an interdisciplinary team consisting of as in the project completed the assess- many of the following key personnel (or similar personnel) as possible: ment. The highest-scoring items in the assessment were the use of standardized — Chief medical officer pain scales, the use of commercially — Nurse executive available or pharmacy-prepared opi- — Director of pharmacy oid solutions, and the availability of — Clinical information technology specialist standardized preprinted order forms — Medication safety officer or manager or computerized prescriber order entry (CPOE) order sets for patient-controlled — Risk management and quality improvement professionals analgesia therapy. The lowest-scoring — At least two staff nurses from different specialty areas items were inclusion of the mg/kg or — At least two staff pharmacists (one clinical and one distribution) mcg/kg dose along with the calculated — At least one active staff physician who regularly orders opioids patient-specific doses for pediatric parenteral opioid orders, pharmacists’ The hospital’s team was charged with the responsibility to accurately and honestly ability to easily access the patient’s evaluate the current status of opioid practices in its facility. Also, hospital leadership opioid status, and restriction of the use was asked to provide their team with sufficient time to complete the assessment. of long-acting opioids to opioid-tolerant Instrument patients. Findings from the assessment revealed opportunities to improve medi- The organization assessment comprised 15 demographic questions, followed by cation safety and established a baseline 45 assessment items subdivided into the nodes of the medication-use process (i.e., of current practices regarding opioid use prescribing, order review, compounding, product storage, administration, and monitor- that can be used to evaluate ongoing ing), as well as items addressing overall organizational structure and patient-controlled improvement. (Pa Patient Saf Advis 2013 analgesia (PCA) therapy. Unless otherwise stated, assessment items refer to opioids Jun;10[2]:59-66.) * The analyses upon which this publication is based were in part funded and performed under Corresponding Author contract number HHSM-500-2012-00022C, entitled “Hospital Engagement Contractor for Matthew Grissinger Partnership for Patients Initiative.” Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 59 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S prescribed, dispensed, and administered — Fully implemented. This item is fully by means of an online data submission to all inpatients and outpatients typically implemented throughout the hospital. tool available on PassKey. seen in most hospitals, including patients Therefore, the choice of “Fully imple- admitted from the emergency department mented” should only have been selected if RESULTS and ambulatory surgery/procedure units. all components of the item were present Tables 1 and 2 list the assessment items As necessary, each team was to investigate in all areas of the hospital. If only one or on which hospitals scored highest and and verify the level of implementation some of the components had been par- lowest, respectively. The complete results with other healthcare practitioners exter- tially or fully implemented in some or all of the assessment can be found online nal to the team. When a consensus on the areas of the hospital, a choice of “Partially at http://patientsafetyauthority.org/ level of implementation for each assess- implemented” was selected. ADVISORIES/AdvisoryLibrary/2013/ ment item was reached, hospitals selected Jun;10(2)/Pages/home.aspx. the appropriate choice for each item Distribution within the assessment. The assessment was distributed in June Organization Characteristics To simplify the scoring process, for the 2012 by e-mail to hospitals participating Of the 29 participating hospitals in the majority of the assessment items, hospitals in the PA-HEN ADE project. It was also PA-HEN ADE project, 58.6% (n = 17) had the following scoring options and cor- posted to the PA-HEN ADE project collab- completed the assessment. Of the hospi- responding definitions to indicate their oration pages on the Authority’s Patient tals responding, 35.3% (n = 6) had fewer level of implementation of practices: Safety Knowledge Exchange (PassKey), a than 100 beds, 35.3% (n = 6) had 100 to secure website to share information, ideas, 299 beds, 11.8% (n = 2) had 300 to 499 — Not implemented. This item has and solutions. Each participating hospital not been implemented within the beds, and 17.6% (n = 3) had 500 beds or was asked to complete and submit only more. These hospitals provided a range of hospital. one assessment. If multiple hospitals from services. Roughly 94.1% (n = 16) provided — Partially implemented. This item has a single health system were participating, pediatric services, 70.6% (n = 12) provided been partially implemented in some each individual hospital was to complete oncology services, 52.9% (n = 9) provided or all areas of the hospital, or this the assessment individually. trauma services, 29.4% (n = 5) provided item has been fully implemented in From September until December 2012, neonatal intensive care services, and some areas of the hospital. facilities submitted their assessment data 17.6% (n = 3) provided transplant services. Table 1. Pennsylvania Hospital Engagement Network Opioid Organization Assessment Items Scored Highest by Hospitals (N = 17)*, † ITEM ITEM DESCRIPTION % NOT % PARTIALLY % FULLY NO. IMPLEMENTED IMPLEMENTED IMPLEMENTED 2 The organization uses a standardized pain scale(s) appropriate to 0.0 5.9 94.1 the patient population to assess a patient’s level of comfort/pain. 17 Pharmacy purchases commercially available parenteral 0.0 5.9 94.1 opioid infusions or prepares opioid infusions in the pharmacy (i.e., nurses do not prepare opioid infusions). 37‡ § Standardized preprinted order forms/CPOE [computerized 6.3 N/A 93.8 prescriber order entry] order sets are used for PCA [patient- controlled analgesia]. 18 A pharmacist double-checks all opioid products before they are 0.0 11.8 88.2 dispensed from the pharmacy, including those opioids placed into ADCs [automated dispensing cabinets]. 21 Morphine and HYDROmorphone are segregated from one 5.9 5.9 88.2 another in pharmacy storage. * Based on percentage of “Fully implemented” responses. In cases in which multiple items had the same percentage of “Fully implemented” responses, items were ranked based on percentage of “Partially implemented” responses. † Percentages may not add up to 100% because of rounding. ‡ One particpating organization indicated that it does not provide intravenous PCA therapy (item no. 33) and was directed to skip the remaining assessment items. Therefore, only 16 out of 17 hospitals answered item no. 37. § Item no. 37 contained “No” and “Yes” answer choices. “No” answer selections are categorized as “Not implemented,” and “Yes” answer selections are categorized as “Fully implemented.” Page 60 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority Table 2. Pennsylvania Hospital Engagement Network Opioid Organizatoin Assessment Items Scored Lowest by Hospitals (N = 17)*, † ITEM ITEM DESCRIPTION % NOT % PARTIALLY % FULLY NO. IMPLEMENTED IMPLEMENTED IMPLEMENTED 9 Parenteral opioid orders include the mg/kg or mcg/kg dose for 58.8 23.5 17.6 pediatric patients along with the total calculated patient-specific dose (e.g., morphine 0.1 mg/kg x 15 kg = 1.5 mg IV every 4 hours prn severe pain). 13 Pharmacists have easy access to the patient’s opioid status 58.8 23.5 17.6 (opioid-naïve/opioid-tolerant) and take it into consideration when profiling or reviewing orders for opioids. 10 Long-acting opioids (e.g., fentaNYL patches, MS Contin® 100 and 52.9 29.4 17.6 200 mg tablets, OxyCONTIN® doses greater than 40 mg) are restricted for use in opioid-tolerant patients and are not used for acute pain management. 3‡ Pain management protocols define opioid-naïve and opioid- 52.9 17.6 5.9 tolerant patients and outline the differences in the management of these patients. 6§ Standardized preprinted order forms/CPOE [computerized 52.9 N/A 47.1 prescriber order entry] order sets are used to prescribe oral and parenteral opioids. (This question does not apply to PCA [patient- controlled analgesia] therapy.) 40** Smart infusion pumps with computer software that is capable of 50.0 6.3 43.8 alerting the user to unsafe opioid doses (i.e., soft and hard stops) are utilized when PCA is administered. 5 Equianalgesic dosing charts for oral, parenteral, and transdermal 47.1 23.5 29.4 opioids (e.g., fentaNYL patches) have been established and are easily accessible to all practitioners when prescribing, dispensing, and administering opioids. * Based on percentage of “Not implemented” responses. In cases in which multiple items had the same percentage of “Not implemented” responses, items were ranked based on percentage of “Partially implemented” responses. † Percentages may not add up to 100% because of rounding. ‡ Item no. 3 included a fourth answer choice: “Not applicable: Our hospital does not have pain management protocols.” This answer was selected by 23.5% of respondents. § Item no. 6 contained “No” and “Yes” answer choices. “No” answer selections are categorized as “Not implemented,” and “Yes” answer selections are categorized as “Fully implemented.” ** One participating organization indicated that it does not provide intravenous PCA therapy (item no. 33) and was directed to skip the remaining assessment items. Therefore, only 16 out of 17 hospitals answered item no. 40. Hospitals were asked to list all of the opi- if so, which disciplines were represented question asked practitioners to identify oids currently used by their practitioners on that team. Only six hospitals (35.3%) the treatment regimen that would make to provide parenteral pain management. stated they had such a team; each of those a patient tolerant to opioids. Only one Every hospital (n = 17) indicated that they teams was composed of at least an anes- of the four proposed orders was cor- used morphine and HYDROmorphone, thesia provider, nurse, and pharmacist. rect. Overall, only 29.1% of all hospitals while 94.1% (n = 16) stated they used answered the question correctly; 34.2% fentaNYL and 70.6% (n = 12) stated they Opioid Status of physicians, 25.5% of nurses, and used meperidine. A majority of hospitals As discussed in the March 2013 issue of 40.5% of pharmacists answered correctly. (70.6%, n = 12) stated that morphine was the Pennsylvania Patient Safety Advisory,1 the In addition, 52.9% of all practitioners the primary opioid used in their facility, PA-HEN ADE project’s opioid knowledge answered “all of the above”; 49.3% of followed by HYDROmorphone (23.5%, assessment, used to assess practitioners’ physicians, 57.4% of nurses, and 37.8% of n = 4). One facility (5.9%) mentioned knowledge of opioids, revealed significant pharmacists thought any one of the treat- that it did not have a primary opioid pre- gaps in the knowledge of opioids. Specifi- ment regimens would classify a patient as scribed for parenteral pain management. cally, practitioners scored low when asked opioid-tolerant. Hospitals were asked if they had an inter- to determine a patient’s opioid status (i.e., This assessment also included items to disciplinary pain management team and opioid-naïve versus opioid-tolerant). The identify gaps in an organization’s practices Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 61 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S regarding a patient’s opioid status, includ- general opioid use were allergies (94.1%, — No. 25b: Prior to the administration ing the following: n = 16), age (88.2%, n = 15), and weight of parenteral opioids, nurses perform — No. 3: Pain management protocols (76.5%, n = 13). The elements selected a baseline assessment. define opioid-naïve and opioid- least often were obstructive sleep apnea — No. 26a: Following the administration tolerant patients and outline the (29.4%, n = 5), asthma/chronic obstruc- of oral opioids, nurses perform a differences in the management of tive pulmonary disease (35.3%, n = 6), postadministration assessment within these patients. and opioid status (47.1%, n = 8); these the hospital-designated time frame. items were also the lowest-scoring items — No. 26b: Following the administra- — No. 10: Long-acting opioids (e.g., fen- for elements screened before PCA therapy tion of parenteral opioids, nurses taNYL patches, MS Contin® 100 and (see Figure 1). perform a postadministration assess- 200 mg tablets, OxyCONTIN® doses greater than 40 mg) are restricted for Patients are at highest risk for opioid- ment within the hospital-designated use in only opioid-tolerant patients. induced respiratory depression during time frame. — No. 13: Pharmacists have easy access the first 24 hours of opioid therapy, and Across all four items, the most commonly to the patient’s opioid status and the apnea-hypopnea index in sleep apnea selected elements that hospitals indicated take it into consideration when pro- patients is highest on the third night after were assessed were pain level and level of filing or reviewing orders. surgery and remains above the preoperative sedation (see Figures 2 and 3). It should baseline out to the seventh postopera- be noted that assessing the pain level does — No. 38: PCA basal infusion rates tive night.3,4 Pre- and postadministration not constitute a complete assessment for are not routinely ordered for opioid- assessment and monitoring are critical a patient on opioid therapy. In fact, the naïve adult patients. to preventing and mitigating respiratory least frequently selected elements in the The first three items listed above were depression. Although respiratory rate is an assessment across all four items included among the lowest-scoring items in the important parameter to obtain, clinically pulse oximetry, capnography, heart rate, entire assessment. More than half of par- significant respiratory depression is not blood pressure, and quality of respira- ticipating hospitals stated that these items defined by a specific number of respira- tions. Interestingly, nurses assessed fewer were not in place. tions per minute.5 Rather, it is defined elements after the administration of by several characteristics of a patient’s either an oral or parenteral opioid as com- Patient Screening and respiratory status and is compared with the pared with before administration. Assessment patient’s baseline respiratory status. For The previously published results of Certain patient characteristics and pre- example, a proper respiratory assessment the opioid knowledge assessment also existing conditions place patients at a during opioid treatment requires the nurse revealed that practitioners had difficulty higher risk for adverse events. These char- to watch the rise and fall of the patient’s identifying which medications could acteristics include sleep apnea, preexisting chest to determine the rate, depth, and potentiate the effects of an opioid, specifi- respiratory conditions, morbid obesity, regularity of respirations.6 In addition, cally HYDROmorphone, on ventilation.1 and concurrent use of other drugs that sedation is a very sensitive indicator of Overall, only 51.5% of all practitioners are central nervous system and respiratory impending opioid-induced respiratory answered the question correctly; 47.6% of depressants.2 depression and precedes clinically signifi- physicians, 49.9% of nurses, and 59.6% cant episodes. Therefore, a comprehensive The assessment included a number of of pharmacists answered correctly. In assessment by nursing of respiratory status items that asked hospitals about specific addition, practitioners struggled to select goes along with an assessment of seda- patient criteria or elements that should be the most important predictor of respira- tion and requires more than counting considered when prescribing opioids, as tory depression in patients receiving a patient’s respiratory rate over a 30- or well as patient assessments that should be intravenous (IV) opioids. Overall, only 60-second period. performed before and after the adminis- 22.4% of all practitioners answered the tration of an opioid. Items that addressed specific elements that question correctly as sedation level; 33.0% are a part of patient assessments performed of physicians, 20.1% of nurses, and 16.0% For example, hospitals were asked to by nurses for patients receiving opioids of pharmacists answered correctly. Thus, identify the elements for which patients were broken down into four distinct items: both project assessments identified weak- are screened that might affect the dose, monitoring parameters, or appropriate- — No. 25a: Prior to the administration nesses in identifying factors contributing ness of general opioid use (no. 7). The of oral opioids, nurses perform a to respiratory depression and in having most commonly selected elements for baseline assessment. processes in place to detect patients expe- riencing respiratory depression. Page 62 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority Figure 1. Elements That Patients Are Screened for When Opioids and Patient-Controlled Analgesia Therapy Are Prescribed PERCENTAGE SCREENED 100 100.0 94.1 93.8 93.8 88.2 80 76.5 70.6 68.8 60 58.8 62.5 52.9 50.0 47.1 40 35.3 29.4 31.3 25.0 25.0 20 MS13223 0 as e s e s a s on ht en f ie tu tu ise tiv Ag ne ag o e g ts cti rg ta sta ei y d uc g se ap ls le W un in t u ar str d Al ta ep lf oi on ob an en na pi sle ed it m lm ic O r s om Re at pu ron ve d he nc re cti ch te ot Co tru a/ Al bs m O th As ELEMENT SCREENED Opioids (no. 7) Patient-controlled analgesia therapy (no. 36) Note: Results are for item no. 7 (“Patients are screened for the following elements which might affect the dose, monitoring param- eters, or appropriateness of opioid use...") and item no. 36 (“Patients are screened for the following elements which might affect the dose, monitoring parameters, or appropriateness of PCA use..."). Standardization — No. 15: Concentrations of parenteral and adjust it as needed. Well-designed The organization assessment queried opioid infusions for adult patients standard order sets, both in electronic and about standardized practices in place are standardized to a single concen- paper formats, can improve safe medica- for safe opioid use. Examples of items tration per drug and are used in at tion use by the following means:8,9 addressing the standardization of practices least 90% of the cases. — Integrating and coordinating care include the following: — No. 16: Concentrations of paren- by communicating best practices — No. 1: Current pain management teral opioid infusions for pediatric through multiple disciplines, levels protocols and guidelines for opioid patients (including neonates) are of care, and services use are available to guide prescrib- standardized to a single concentra- — Modifying practice through evidence- ers, pharmacists, and nurses when tion per drug and are used in at least based care opioids are prescribed, dispensed, 90% of the cases. — Reducing variation and unintentional administered, or monitored. — No. 37. Standardized preprinted oversight through standardized format- — No. 2: The organization uses a stan- order forms/CPOE order sets are ting and clear presentation of orders dardized pain scale(s) appropriate used for PCA. — Enhancing workflow with pertinent to the patient population to assess a Standardized protocols and order sets, instructions that are easily under- patient’s level of comfort/pain. either electronic or preprinted in paper stood, intuitively organized, and — No. 6: Standardized preprinted order systems, that incorporate pain and seda- suitable for direct application to cur- forms/computerized prescriber order tion scales can serve as a guide to help rent information management systems entry (CPOE) order sets are used to clinical personnel quickly and accurately prescribe oral and parenteral opioids. select the appropriate dose of medication Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 63 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 2. Assessments Performed by Nurses Prior to and Following Administration of Oral Opioids PERCENTAGE SCREENED 100 100.0 100.0 94.1 88.2 80 76.5 70.6 64.7 60 58.8 58.8 52.9 47.1 40 35.3 35.3 20 11.8 11.8 MS13224 0 0.0 0.0 rm t te ns e re n l er en r fo en ve ag o at io t* ra su th ed tio le er sm g id tr at O es ry ra in io ed ar in y p es pr to at op pi Pa He fs el ss ira es d tin : A lo ed of oo fr sp ve ou e r s se yo Bl Re bl Le he o ca lit ot st d ua no pli La Q ap tr ot N ELEMENT ASSESSED Prior to administration (no. 25a) Following administration (no. 26a) Note: Results are for item no. 25a (“Prior to the administration of oral opioids, nurses perform a baseline assessment of the follow- ing..."). and item no. 26a (“Following the administration of oral opioids, nurses perform a postadministration assessment within the hospital-designated time frame of the following..."). * “Last dose of opioid or other sedating agent” was not an answer selection for item no. 26a. — Reducing the potential for medica- safety did not appear to negatively orders for parenteral opioids included tion errors through integrated safety affect patients' satisfaction with pain the organization’s approved pain scale to alerts and reminders management. assist nurses in determining the appropri- — Reducing unnecessary calls to physi- The first item in the assessment asked if ate dose to administer (e.g., Give 1 mg for cians for clarifications and questions hospitals have current pain management moderate pain [scale 4-7] and 2 mg for about orders protocols and guidelines for opioid use severe pain [scale 8-10]) were diverse. Three However, if standard order sets are not available to guide prescribers, pharmacists, hospitals (17.6%) stated they did not allow carefully designed, reviewed, and main- and nurses when opioids are prescribed, range-of-dose orders, five (29.4%) stated tained to reflect best practices and ensure dispensed, administered, and monitored. this was fully implemented, and nine clear communication, they may actually Roughly one-third (35.3%, n = 6) of the (52.9%) indicated that they sometimes or contribute to errors. In relation to opi- hospitals indicated that this item was never followed this practice. oids, one study demonstrated that the not in place, while almost half (47.1%, Less than half of the hospitals (47.1%, implementation of standard order sets n = 8) stated that this item was partially n = 8) revealed that they used standard- for PCA therapy resulted in a dramatic implemented. ized preprinted order forms or CPOE decrease in the number of cases of severe Almost all (94.1%, n = 16) hospitals stated order sets to prescribe oral and parenteral respiratory depression and increased they used a standardized pain scale appro- opioids. Of these, only 37.5% (n = 3) use of the order set for patients new to priate to the patient population to assess a included the recommended doses for opioid therapy.10 Furthermore, changing patient’s level of comfort/pain. However, parenteral opioids to guide appropriate the order sets to improve medication their responses to whether range-of-dose dosing of opioids and 25.0% (n = 2) Page 64 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority Figure 3. Assessments Performed by Nurses Prior to and Following Administration of Parenteral Opioids PERCENTAGE SCREENED 100 100.0 94.1 80 82.4 76.5 76.5 70.6 70.6 60 58.8 58.8 47.1 47.1 47.1 40 29.4 20 23.5 23.5 MS13225 11.8 11.8 11.8 5.9 0 0.0 0.0 en r rm nt te ns e re n ry hy l er ve ag o at io t* ed fo e et ra su th tio ap g id le er ssm tr at im O es in io ry ra gr ed ar in ox pr to at op y p se pi no Pa He fs ira es As se d ap ed of lo oo fr sp l Pu tin e: C r s se ve yo Bl Re el ou bl he o Le t r ca lit ot st d ua no pli La Q ap ot N ELEMENT ASSESSED Prior to administration (no. 25b) Following administration (no. 26b) Note: Results are for item no. 25b (“Prior to the administration of parenteral opioids, nurses perform a baseline assessment of the following...") and item no. 26b (“Following the administration of parenteral opioids, nurses perform a postadministration assess- ment within the hospital-designated timeframe of the following...") * “Last dose of opioid or other sedating agent” was not an answer selection for item no. 26b. included orders for naloxone and direc- opioid (e.g., morphine) to an equivalent selection and dosing of opioids. But when tions for use on those forms. When dose of another opioid (e.g., HYDRO- asked whether pharmacists had access to combining those hospitals that did not morphone) or when converting from an a patient’s opioid status, almost 60% have standardized order forms (52.9%, oral formulation (e.g., oral morphine) to (n = 10) of facilities stated that the phar- n = 9) with those that did not include a parenteral formulation (e.g., IV mor- macy did not have access to or did not recommend doses of opioids or orders for phine). When asked whether hospitals take this into consideration when profiling naloxone, 64.7% (n = 11) of the hospitals had established equianalgesic dosing or reviewing orders, while nearly 24% either did not provide guidance to pre- charts and made them easily accessible (n = 4) of hospitals sometimes pro- scribers on appropriate dosing or did not to all practitioners when prescribing, dis- vided this access. In addition, in the include an order for naloxone with the pensing, and administering opioids, five demographic section of the assessment, ordered opioid. hospitals (29.4%) had fully implemented hospitals were asked whether their phar- The opioid knowledge assessment this strategy, while almost half (47.1%, macy order entry systems provided the asked practitioners which dose of IV n = 8) stated this was not in place. following functionalities: HYDROmorphone best represents an It could be assumed, then, that the — Dose range checking for maximum equianalgesic dose of IV morphine 2 mg.1 aforementioned items reveal that many single doses Overall, 67.2% of participants correctly hospitals are not providing prescribers — Dose range checking for maximum selected IV HYDROmorphone 0.4 mg. with guidance for the appropriate use of total daily doses Providing equianalgesic dosing charts opioids and thus are relying solely on the — Hard stops (catastrophic doses) for within facilities can assist practitioners knowledge and education of their prescrib- doses known to cause serious harm in appropriately converting a dose of one ers and pharmacists to catch inappropriate Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 65 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Nearly 53% (n = 9) of participating hos- CONCLUSION baseline of current practices around pitals stated that their system could check Findings from the PA-HEN Organiza- opioid use that can be used to evaluate for maximum single doses, but less than tion Assessment of Safe Opioid Practices improvement and identify statewide pri- a quarter (n = 4) provided maximum total demonstrate an opportunity to improve orities. Certainly, technological solutions daily doses checks and only 5.9% medication safety with the use of opioids such as CPOE, bar coding, and fully inte- (n = 1) had hard stops for catastrophic within hospitals. Hospitals that completed grated information systems can be helpful doses. Therefore, most hospitals are the opioid organization assessment spent in improving safe practices with opioids. relying solely on the diligence of their considerable time evaluating their medi- However, as these survey findings show, clinical staff to catch inappropriate doses cation-use systems and demonstrated an there is ample room for improvement with of opioids. exemplary commitment to safety, regard- less costly and less difficult-to-implement less of the results. Equally important, this error reduction strategies such as standard- organization assessment established a izing processes and practices within each organization. NOTES 1. Grissinger M. Results of the opioid study. Presented at: American Society of 8. Institute for Safe Medication Practices. knowledge assessment from the PA Hos- Anesthesiologists 2008 Annual Meeting; ISMP’s guidelines for standard order pital Engagement Network adverse drug 2008 Oct 22; Orlando (FL). sets [online]. 2010 [cited 2013 Mar 14]. event collaboration. Pa Patient Saf Advis 5. Pasero C, Portenoy RK, McCaffery M. http://www.ismp.org/Tools/guidelines/ [online] 2013 Mar [cited 2013 Mar 14]. Opioid analgesics. In: McCaffery M, StandardOrderSets.asp. http://www.patientsafetyauthority.org/ Pasero C. Pain: clinical manual. 2nd ed. 9. Institute for Safe Medication Practices. ADVISORIES/AdvisoryLibrary/2013/ St. Louis (MO): Mosby; 1999:161-299. ISMP develops guidelines for standard Mar;10(1)/Pages/19.aspx. 6. Stemp LI, Ramsay MA. Oxygen may mask order sets. ISMP Med Saf Alert Acute Care 2. Joint Commission. Safe use of opioids in hypoventilation—patient breathing must 2010 Mar 11:15(5):1-4. hospitals [online]. Sentinel Event Alert be ensured [letter to the editor online]. 10. Weber LM, Ghafoor VL, Phelps P. Imple- 2012 Aug 8 [cited 2013 Mar 14]. http:// APSF Newsl 2005 [cited 2013 Mar 14]. mentation of standard order sets for www.jointcommission.org/assets/1/18/ http://www.apsf.org/newsletters/pdf/ patient-controlled analgesia. Am J Health SEA_49_opioids_8_2_12_final.pdf. winter2006.pdf. Syst Pharm 2008 Jun 15;65(12):1184-91. 3. Pasero C. Assessment of sedation dur- 7. Institute for Healthcare Improvement. ing opioid administration for pain Reduce adverse drug events involving management. J Perianesth Nurs 2009 narcotics and sedatives [online]. 2012 Jun;24(3):186-90. Mar 28 [cited 2013 Mar 14]. http://www. 4. Chung F, Liao P, Yegneswaran B, et al. ihi.org/knowledge/Pages/Changes/ The effect of surgery on the sleep archi- ReduceAdverseDrugEventsInvolvingNar- tecture of patients at risk of OSA—a pilot coticsandSedatives.aspx. Page 66 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 2—June 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. 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