Opioids Can Cause Adverse Events and Patient Deaths: ECRI Institute Patient Safety Organization’s Deep Dive Analysis

Despite the focus on appropriate use of opioids for pain management, ECRI Institute Patient Safety Organization (PSO) found that there are many hospitals that continue to experience opioid-related adverse events and deaths. To help prevent further patient harms and deaths, PSO conducted a deep dive analysis of adverse events related to opioids in the acute care setting.

Here are key findings from PSO’s Executive Brief:

  1. Harms from Opioids are Frequent – “Opioid-related adverse events can cause significant morbidity, even mortality. Unfortunately, opioid-related harm is not rare. Opioids are the second most frequent class of medications to cause adverse drug reactions in hospitalized patients, trailing only loop diuretics”. In a review of 357 anesthesia closed malpractice claims, 77% resulted in death or severe brain damage.
  2. Opioid-Related Adverse Events are Costly – “The median payment was $216,750, but about one in four payments was greater than $600,000 … nearly $54,000 in excess charges could be attributed to postoperative respiratory failure (resulting from any cause, not just opioids). This injury was also associated with an excess hospital length of stay of nine days.”
  3. Opioid Adverse Events are Preventable – “Nearly all cases of respiratory depression (97%) were preventable, according to physician reviewers.”
  4. Failure Modes Most Associated with Patient Harm
    • Monitoring: Failure to monitor analgesic effectiveness, failure to monitor sedation level
    • Prescribing: Inadequate risk assessment before prescribing, polypharmacy, failure to determine opioid tolerance, wrong dose, wrong rate or frequency, wrong route
    • Administration: Patient-controlled analgesia by proxy, unavailability of a reversal agent, failure to remove a used fentanyl patch

To help prevent further patient harms and deaths, we offer these three clinical education podcasts to help make improve practices:

  • Monitor Your Patients Better – ECRI says that inadequate monitoring for respiratory depression in patients receiving opioids poses the greatest risk to patients and assigned it a risk map of 80. In order to improve clinical understanding of how patient harm from opioids may be reduced, Lynn Razzano, (RN, MSN, ONCC) and Michael Wong, JD of the Physician-Patient Alliance for Health & Safety (PPAHS) had a discussion with ECRI’s Patient Safety Analyst, Stephanie Uses, PharmD, MJ, JD. The podcast can be viewed here.
  • Conduct Better Patient Assessment – The Society of Hospital Medicine developed a guide for Reducing Adverse Drug Events Related to Opioids (RADEO). In this podcast, lead author, Thomas W. Frederickson MD, FACP, SFHM, MBA, discusses how to better assess patients.
  • Develop a Comprehensive Monitoring Strategy – According to Dr. Frederickson, a key to accounting for such lagging indicators of respiratory depression is the development of a comprehensive monitoring strategy, including pulse oximetry and capnography.  During this podcast, he highlights the unique advantages and limitations of these monitoring technologies.

Use these resources to help prevent further patient harms and deaths. As well, please help your colleagues and tell us what resources you find valuable in the comment section below.

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