R E V I E W S & A N A LY S E S Results of the 2013-2014 Opioid Knowledge Assessment: Progress Seen, but Room for Improvement Michael J. Gaunt, PharmD INTRODUCTION* Sr. Patient Safety Analyst Published studies have examined errors related to knowledge deficiencies regarding Dalia Alghamdi, BSc Pharm, MSc HCPM the use of opioids.1,2 In 2012, prompted by the literature and as part of the Centers Patient Safety Analyst for Medicare and Medicaid Services–sponsored Pennsylvania Hospital Engagement Matthew Grissinger, RPh, FISMP, FASCP Manager, Medication Safety Analysis Network (PA-HEN) adverse drug event (ADE) project, the Pennsylvania Patient Safety Authority partnered with the Pennsylvania Medical Society to develop an opioid Pennsylvania Patient Safety Authority knowledge assessment tool to assess practitioners’ knowledge about the use of opioids.3 The questions covered issues associated with the use of opioids, including differences ABSTRACT between opioid-naïve and opioid-tolerant patients, indications for long-acting opioids, In 2012, the Pennsylvania Patient and patient-specific conditions that require a lower starting dose of opioids. Safety Authority provided hospitals par- The results of the 2012 knowledge assessment identified basic knowledge gaps by prac- ticipating in the Pennsylvania Hospital titioners, particularly in the areas of identifying the predictors of respiratory depression Engagement Network adverse drug in patients receiving intravenous (IV) opioids, defining what constitutes an opioid- event collaboration with an 11-question tolerant patient, and choosing medications that could potentiate the effects of an opi- opioid knowledge assessment tool to oid with respect to a patient’s ventilation. The Authority published the results of the assess practitioners’ knowledge about 2012 assessment in the March 2013 issue of the Pennsylvania Patient Safety Advisory.3 the use of opioids. In the winter of 2013-2014, the same assessment tool METHODS was distributed to reassess any changes in knowledge in the year elapsed from In the winter of 2013-2014, the collaboration team distributed the assessment tool devel- the first assessment. Overall, improve- oped and used in 2012 for the first round of the opioid knowledge assessment3 to the ment in knowledge about the use of 12 hospitals currently participating in the collaboration that also participated in the opioids did occur from 2012 to 2013- assessment in 2012. The tool was developed to assess prescribers’, pharmacists’, and 2014. There was a small but statistically nurses’ knowledge about the use of opioids. The assessment consisted of two demo- significant increase in the percentage of graphic questions—the practitioner’s position and how long he or she has worked in the correct answers selected in 7 of the 11 facility—followed by 11 multiple-choice assessment questions. The questions covered a questions. The lowest-scoring questions variety of problematic issues associated with the use of opioids, including the following: continue to be those that encompass —— Differences between “opioid naïve” and “opioid tolerant,” and what constitutes or topics identifying the predictors of respi- makes a patient “opioid tolerant” ratory depression in patients receiving —— Indications for long-acting opioids (who and/or when they should be prescribed) intravenous opioids, defining what con- —— Comparative dosing between two different opioids, particularly morphine and stitutes an opioid-tolerant patient, and HYDROmorphone choosing medications that could poten- tiate the effects of an opioid with respect —— Patient-specific conditions that require a lower starting dose of opioids to a patient’s ventilation. While educa- —— The impact of concomitant medications in combination with opioids tion is important, a mix of high-leverage —— Monitoring the effects of opioids strategies (e.g., fail-safes, constraints, The multiple-choice assessment was built and conducted in a web-based survey tool, standardization) will be needed to which was distributed by e-mail. Users were required to enter an organization-specific improve and sustain the safe and four-digit code to associate results with specific facilities. No practitioner identities or appropriate use of opioids. (Pa Patient identifiers were collected in either assessment. A paper version was also used by orga- Saf Advis 2014 Sep;11[3]:124-30.) nizations to capture responses from practitioners who were unable to respond online. Corresponding Author This tool was released on September 27, 2013, and the last day of data submission Matthew Grissinger was March 13, 2014. A listing of the assessment questions can be found in the Opioid Knowledge Self-Assessment, which is available for use at http://patientsafetyauthority. org/EducationalTools/PatientSafetyTools/opioids/Pages/home.aspx. Scan this code with your mobile device’s QR reader * The analyses upon which this publication is based were in part funded and performed under to access the contract number HHSM-500-2012-00022C, entitled “Hospital Engagement Contractor for Part- Authority's toolkit nership for Patients Initiative.” on this topic. Page 124 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority RESULTS Table. Percentage of Respondents to the Opioid Knowledge Assessment by Type of Participating Hospitals Practitioner for Each Round of the Assessment In 2012, there were 29 hospitals participat- PRACTITIONER TYPE 2012 (%) 2013-2014 (%) ing in the PA-HEN ADE collaboration. Attending/staff physician 18 13 Twenty-four of those hospitals participated Resident physician/physician in training 9 7 in the 2012 opioid knowledge assessment. In 2013-2014, there were 22 hospitals, Physician assistant/nurse practitioner 4 3 some of which were new to the collabora- Registered nurse 48 62 tion beginning in 2014, participating in Pharmacist 16 12 the PA-HEN ADE collaboration. In order to compare results between 2012 and 2013- Other or missing 6 3 2014, only those organizations (n = 12) that participated in the 2012 assessment were invited to participate in 2013-2014. than 5 years, 5 to 9 years, 10 to 14 years, There was statistically significant improve- Ten (83.3%) collaborating hospitals par- 15 to 19 years, or 20 or more years. More ment for three groups: (1) attending/ ticipated in both the 2012 and 2013-2014 respondents had worked in their current staff physicians (p < 0.001), (2) physician opioid knowledge assessments. facility for less than five years than other assistants/nurse practitioners (p = 0.02), lengths of time. Overall, there was no and (3) registered nurses (p < 0.001). The Practitioner Characteristics statistically significant difference in the other three groups, resident physicians/ duration of time working at the current physicians in training, pharmacists, and Practitioners, including physicians, medical facility between 2012 and 2013-2014. “other or missing,” showed improvement residents, physician assistants, nurse prac- from 2012 to 2013-2014, but the improve- titioners, pharmacists, and nurses, from the 10 hospitals that signed up for the col- Overall Scores ment was not statistically significant. laboration participated in the 2013-2014 For this analysis, comparisons were made assessment. In 2012, 2,223 practitioners between the overall number of questions Individual Questions started the survey, but only 1,758 (79%) answered correctly in 2012 and 2013-2014 The percentage of correct answers for completed it. In 2013-2014, 1,122 practitio- (see Figure 1). Only those respondents each question from each round of the ners started the survey, but only 829 (74%) who answered all 11 questions were opioid knowledge assessment can be seen completed it. A chi-square test comparison included. In 2012, the median correct in Figure 2. There was improvement from of these completion rates found that this score was 6 of 11 questions, and the aver- 2012 to 2013-2014 in 10 of the 11 ques- difference in completion rates, though age was 6.5, with a standard deviation tions. For questions 1, 2, 4, 5, 6, 7, and 8, small, is statistically significant (p < 0.001). of 1.9. In 2013-2014, the median correct the improvement was statistically signifi- score was 7 of 11 questions, and the aver- cant. The largest improvements were seen Similar to the results from 2012, more age was 7.0, with a standard deviation in questions 1, 2, 7, and 8. The percent- registered nurses (62%) completed the of 2.1. A comparison of these overall age of correct answers for question 10, a opioid knowledge assessment than any scores found that the average score was case-based question assessing the respon- other type of practitioner (see the Table). statistically significantly higher in 2013- dents’ knowledge of adjusting the pain A chi-square test for independence found 2014 than 2012 (p < 0.001). However, medication regimen based upon patient statistical significance in the types of prac- the improvement of 0.5 more questions response, declined in 2013-2014. titioners who participated in 2012 versus answered correctly in 2013-2014, on aver- 2013-2014 (p < 0.001). Respondents in Similar to the results from 2012, the three age, is small. The percentage of people lowest-scoring assessment items in 2013- 2012 achieved slightly higher levels of who answered all 11 questions correctly prior education than respondents in 2014 were identifying the most important increased from 1.6% in 2012 to 8.9% in predictor of respiratory depression in 2013-2014. Thus, a comparison of overall 2013-2014; this difference was statistically opioid knowledge scores could be biased patients receiving IV opioids, defining reliable using the chi-square test (X2[2] = what constitutes an opioid-tolerant in favor of the 2012 respondents. 80.0, p < 0.001). patient, and choosing which medication The length of time a practitioner had Analysts also compared the overall scores could potentiate the effects of HYDRO- worked at his or her current facility was from 2012 with those from 2013-2014 morphone on ventilation. also assessed. Respondents could choose separately for each practitioner type. one of the following selections: fewer Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 125 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 1. Percentage of Respondents by Overall Score (number of correct answers out of 11) in 2012* and 2013-2014† PERCENTAGE OF RESPONDENTS 25 2012 20.9 2013-2014 20.4 20 19.5 18.1 15.6 16.0 15 14.5 12.7 10 9.8 8.4 8.9 8.3 6.6 5 4.6 4.0 4.1 2.9 1.4 1.6 0.8 0.1 0.0 0.3 0.5 0 0 1 2 3 4 5 6 7 8 9 10 11 MS14415 OVERALL SCORE * 1,758 respondents completed the opioid knowledge assessment in 2012. † 829 respondents completed the opioid knowledge assessment in 2013-2014. Note: A t-test comparison of the overall scores found that the average score was statistically significantly higher in 2013-2014 than 2012 (t [2,585] = 6.8, p < 0.001). A Wilcoxon test found the same thing (p < 0.001). Predictor of Opioid-Induced percentage of respondents (of those who not been chronically receiving opioids on Respiratory Depression completed the entire knowledge assess- a daily basis) or opioid tolerant (i.e., the Opioid-induced respiratory depression can ment) answering the question correctly patient has been chronically receiving opi- be defined as a decrease in the effectiveness increased from 24% in 2012 to 37% in oids on a daily basis for a specified amount of an individual’s ventilatory function after 2013-2014 (p < 0.001). While an improve- of time7,8) before prescribing, dispensing, opioid administration.4 Sedation generally ment from a quarter to over a third of or administering an opioid. precedes significant respiratory depres- respondents answering the question Question 1 of the assessment asked sion.5,6 Opioid-induced sedation occurs on correctly is significant, it still means that respondents to select which treatment a continuum ranging from full conscious- 63% of the respondents were unable to regimen would meet the definition of ness to complete loss of consciousness and accurately identify important predictors to opioid tolerance. Only one of the four respiratory arrest. Unintended advancing increase the safe use of IV opioids. treatment regimens was correct. Overall, of sedation occurs at increasingly higher the percentage of respondents (of those levels along the continuum of sedation, Opioid Tolerance who completed the entire knowledge impairing both arousal mechanisms and The decision to use a potent and/or assessment) answering the question cor- content processing. long-acting opioid and the selection of an rectly increased from 29% in 2012 to 37% Question 2 of the assessment asked appropriate medication is dependent upon in 2013-2014 (p < 0.001). However, this respondents to select the most important an assessment of the patient’s opioid sta- leaves 63% of respondents who selected predictor of respiratory depression in tus. This means determining if the patient regimens that would have indicated the patients receiving IV opioids. Overall, the is either opioid naïve (i.e., the patient has patient was opioid naïve. Page 126 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority Figure 2. Percentage of Respondents Who Chose the Correct Answer for Each Assessment Item, 2012 and 2013-2014 ASSESSMENT ITEM 1. Patients who are considered opioid-tolerant are those who have been 29 37 (p < 0.001) 2. The most important predictor of respiratory depression in patients 24 receiving intravenous (IV) opioid analgesics in the hospital setting is 37 (p < 0.001) 3. Which of the following statements about long-acting opioids is true? 58 62 (p = 0.058) 4. Which of the following best represents the equianalgesic dose of IV 69 HYDROmorphone to IV morphine 2 mg? 73 (p = 0.035) 5. Which patient-specific parameters might cause you to consider 67 reducing the initial dose of HYDROmorphone? 71 (p = 0.017) 6. The best choice to manage this patient’s pain and restlessness is to 63 69 (p = 0.005) 7. Which of the following patient-specific parameters are the most 76 important to monitor in patients receiving IV HYDROmorphone? 81 (p < 0.001) 8. Which of the following statements is correct in regard to the 77 HYDROmorphone 1 mg order? 85 (p < 0.001) 9. Which of the following agent(s) can potentiate the effects of 51 HYDROmorphone on ventilation? 55 (p = 0.13) 60 10. What would be the best option to control this patient’s pain? 59 (p = 0.53) 11. Which patient-specific parameters might cause you to consider 71 reducing the subsequent dose of opioid? 73 (p = 0.15) MS14416 0 20 40 60 80 100 2012 2013-2014 PERCENTAGE OF RESPONDENTS Note: The complete Opioid Knowledge Self-Assessment tool, including the target answers, is available at http://patientsafety authority.org/EducationalTools/PatientSafetyTools/opioids/Documents/assessment.pdf. Medications That Potentiate the (e.g., benzodiazepines, antihistamines, ALPRAZolam) could potentiate the effects Effects of Opioids on Ventilation diphenhydrAMINE, sedatives) are also at of HYDROmorphone on ventilation. Patients with sleep apnea or those who are higher risk of adverse events.9,10 Question 9 Overall, the percentage of respondents (of morbidly obese are at increased risk for of the knowledge assessment was designed those who completed the entire knowledge experiencing adverse events from the use to measure practitioners’ ability to iden- assessment) answering the question cor- of opioids. Patients who are concurrently tify which medications (i.e., atorvastatin, rectly increased from 51% in 2012 to 55% receiving other medications that are central FLUoxetine, ALPRAZolam, atorvastatin in 2013-2014. However, the improvement nervous system or respiratory depressants and ALPRAZolam, or FLUoxetine and was not statistically significant (p < 0.13). Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 127 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Adjusting the Treatment —— Choosing which medication could use a mix of educational methods or Regimen in Response to the potentiate the effects of HYDRO- interventions appear to effect change in Patient’s Pain morphone on ventilation physician knowledge and practice, but Minimizing the risk of adverse effects The highest percentage of correct answers due to its nature, the change may wane from the use of opioids is important. for any one question in 2013-2014 was over time.12,13 While knowledge is neces- However, effectively managing and treat- 85% for question 8, which asked prac- sary in the delivery of safe and effective ing a patient’s pain is also important. titioners if a starting dose of 1 mg of medical care, it is not sufficient by itself Effectively monitoring a patient’s response HYDROmorphone for an opioid-naïve to effect change in practitioner behavior 80-year-old patient was appropriate. This or patient outcomes.12 This is in part why to opioids and appropriately adjusting question also had the highest percent- strategies, such as education, that rely on therapy contributes to both safe and effec- age of correct answers (77%) in 2012. individual performance will likely be inef- tive pain management. Question 10 of the In June 2011, the US Food and Drug fective when used alone in attempting to knowledge assessment asked practitioners Administration approved changes in prevent errors.14 to select the most appropriate treatment plan for a patient who continued to have the official prescribing information for The intent of the opioid knowledge moderate to severe pain following the HYDROmorphone. As a result, drug assessment was to assist organizations administration of IV HYDROmorphone information compendia and databases in identifying basic knowledge gaps by 0.2 mg. Unlike the improvement seen in were updated to reflect the new dosing practitioners, which would hopefully spur the percentage of correct answers for all information. It is likely that these higher- organizations to address these gaps and of the other knowledge assessment ques- level systematic changes, beyond any possibly assess staff knowledge about other tions, the percentage of correct answers educational efforts, contributed to this high-alert medications. In the course of overall for question 10 declined from statistically significant improvement. the collaboration, each facility was respon- 2012 (60% correct) to 2013-2014 (59% Causes of medication errors include sible for providing education to address correct); however, this decline was not breakdowns due to inadequate staff ori- identified deficiencies, both collabora- statistically significant. entation, ongoing education, supervision, tion-wide and facility-specific. Facilities and competency validation.11 Examples of indicated these educational efforts DISCUSSION errors in part due to deficiencies in staff ranged from physician-specific programs education and competency are inappropri- to broader efforts for all staff. The ADE It appears that improvement in current project team did not provide educational knowledge about the use of opioids did ate medication doses or errors in patient materials specific to the deficits identified occur from 2012 to 2013-2014. Results of assessment and monitoring due to lack from the assessment results to facilities, the 2013-2014 opioid knowledge assess- of knowledge about particular patient so the responsibility of developing and/ ment indicate there was improvement in populations; medication errors by new or or providing any educational efforts or overall scores for all practitioner types, reassigned (“float”) staff who are required materials was up to each separate facility. with statistically significant improvements to perform unfamiliar tasks or give This could have led to a nonstandard- for (1) attending/staff physicians, (2) unfamiliar medications without proper ized approach to the education provided physician assistants/nurse practitioners, orientation, education, or supervision; within facilities (e.g., type of material, staff and (3) registered nurses. There were and errors with new medications given included in educational efforts, method also statistically significant increases in to patients without full knowledge of the of providing education, monitoring that the percentage of correct answers for 7 preparation, dose, route, action, or effects the education was successful), which may of the 11 questions. However, the degree to anticipate.11 have limited the increases in selecting the of improvement from 2012 to 2013-2014 Organizations often are under the belief correct answers in the 2013-2014 Opioid is small. Significant percentages of prac- that when errors occur, providing staff Knowledge Self-Assessment. titioners, between 15% and 63% for a education is an effective stand-alone Although staff education alone is an insuf- given question, continue to have gaps in strategy in preventing medication errors. ficient approach to error reduction, it does knowledge about opioids, particularly in However, two meta-analyses of continuing play an important role when combined the following areas: medical education (CME) activities and with system-based error reduction strate- —— Identifying the most important pre- interventions found that didactic and gies.14 It is important that practitioners dictor of respiratory depression in passive learning interventions appear to receive sufficient orientation to medica- patients receiving IV opioids have little to no effect in changing physi- tion use and undergo baseline and annual cian performance or patient outcome.12,13 competency evaluation of knowledge and —— Defining what constitutes an opioid- CME activities that are interactive or skills related to safe medication practices, tolerant patient Page 128 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority including new medications, nonformulary Constraints opioids are prescribed, dispensed, medications, high-alert medications, and —— Limit the variety of opioids, con- administered, or monitored.23 error prevention.11,14 Providing practi- centrations of each opioid, and —— Implement a standardized pain tioners involved in medication use with formulations of each opioid included scale(s) appropriate to the patient ongoing education about medication error on the hospital formulary.15 population to assess a patient’s level prevention and the safe use of drugs that of comfort/pain.23 —— Prescribing have the greatest potential to cause harm if * Consider requiring prescribers —— Use standardized preprinted order misused is also important.11 For example, to undergo a privileging process forms and computerized prescriber organizations may consider providing staff to verify proficiency with PCA order entry (CPOE) order sets to pre- with ongoing education about medication pain management.19 scribe oral and parenteral opioids.23 errors that have occurred within the orga- nization and in other organizations, as well * Consider restricting fentaNYL —— Standardize concentrations of par- as strategies to prevent these errors. The PCA use to anesthesia or pain enteral opioid infusions for adult use of active and interactive modalities in management team members patients to a single concentration per these educational activities, increasing the only.20 drug, and use these in at least 90% length of contact time, and continuing * Implement standard order sets of the cases.23 contact can contribute to a larger effect of for PCA therapy, with all sec- —— Standardize concentrations of paren- the educational activities.13 tions completed, and limit verbal teral opioid infusions for pediatric In order to see greater improvement in orders to dose changes.19 patients (including neonates) to a practitioner knowledge of opioids, safe * Take into consideration important single concentration per drug, and use and appropriate use of opioids, and pre- information about the patient these in at least 90% of the cases.23 vention of adverse events from opioids, that could affect the prescribing —— Standardize preprinted order forms the expansion (or in some cases the of opioids (e.g., patient’s current and CPOE order sets used for PCA.23 introduction) of extensive opioid and medication profile for drugs with —— Establish protocols for reversal pain management education and train- additive central nervous system or agents that can be administered with- ing in medical, pharmacy, and nursing respiratory depressant side effects, out additional physician orders when education programs and new-practitioner age, renal function, total current warranted.24 training will be necessary. However, to opioid therapy).21 prevent harm with the use of opioids, —— Storage Redundancies a mix of high-leverage strategies (e.g., —— Implement an independent double * Avoid storing concentrated oral fail-safes, forcing functions, constraints, check for all parenteral opioids that standardization), some of which are high- forms of opioids in floor stock and automated dispensing cabi- are compounded in the pharmacy.15 lighted below, can be implemented in nets (ADCs). 16 —— At the point of administration, addition to education. * Store only the smallest-size pack- implement an independent double age, concentration, and dose of check with each new infusion bag, Fail-Safes and Forcing Functions opioids in floor stock and ADCs. 16 bottle, or syringe, as well as with —— Use smart infusion pumps (i.e., changes in the rate of infusion of infusion pumps with dose error * Store each medication in a sepa- parenteral opioids.15,16 reduction software) with soft and rate, lock-lidded bin or drawer hard stops enabled to alert the user in the ADC to help prevent —— At the point of administration, to unsafe doses for continuous opi- drug-selection errors. In the implement an independent double oid infusions and patient-controlled pharmacy, segregate prefilled check with each new PCA infusion analgesia (PCA) therapy.15 syringes and vials of these drugs, bag, bottle, or syringe, as well as with —— Use oral syringes for administration especially if they contain the changes in the rate of PCA adminis- of oral liquid products.16 To fur- same concentration.22 tration of parenteral opioids.15 ther reduce the risk of unintended administration of oral medications Standardization CONCLUSION via the IV route, have pharmacy —— Ensure current pain management The results of the 2013-2014 knowledge dispense all oral liquids that are not protocols and guidelines for opioid assessment illustrate that gaps in practi- commercially available as unit dose use are available to guide prescrib- tioners’ knowledge about opioids continue product in an oral syringe.17,18 ers, pharmacists, and nurses when to exist. While education on statewide Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 129 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S and local levels and in-facility staff training new-practitioner training is needed. Also, Acknowledgments programs are necessary and can produce the development of standardized approaches Jonathan R. Treadwell, PhD, associate director of the Evidence-based Practice Center, ECRI Insti- minor improvements in levels of knowledge, and protocols to pain management and tute, consulted on and contributed to statistical more needs to be done. Better incorpora- monitoring can help institutionalize best testing for this article. tion of education about opioids in medical, practices regarding the use of opioids. pharmacy, and nursing school programs and NOTES 1. Dy SM, Shore AD, Hicks RW, et al. Medi- 9. Joint Commission. Safe use of opioids in 17. Shah-Mohammadi AR, Gaunt MJ. 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[cited 2014 Washington (DC): American Pharmacists Jun 9]. https://www.tirfremsaccess.com/ Association; 2007:344-97. TirfUI/rems/pdf/education-and-ka.pdf Page 130 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 3—September 2014. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2014 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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