The use of opioids for pain relief in inpatient hospitals can lead to serious potential adverse effects, including respiratory depression and drug interaction. On August 8, 2012, The Joint Commission published a Sentinel Event Alert: “Safe use of opioids in hospitals”. The alert contains information about potential causes of the adverse effects possible with the use of opioids as well as solutions that, if implemented by healthcare facilities, can reduce the risk of patient safety impacts from the use of opioids.
We can present the information provided by The Joint Commission in a Cause Map, or visual root cause analysis. We begin with the impacts to the goals. In this case, we look specifically at two potential impacts to the patient safety goal – the risk of drug-drug interactions and respiratory depression involving opioids.
Drug-drug interactions can result when a patient is taking another drug that interacts with opioids. In this case, the provider prescribing the opioid is unaware of the potential interaction between the drugs prescribed or is unaware of the patient’s drug history, because a complete history is unavailable and a patient is either unable or unwilling to provide a compete list. While drug-drug interactions are possible with any level of opioid, the over-use of opioids for pain relief is a particular concern. Opioids can be effectively used for pain relief, but over-use can occur when a high dose is needed to manage pain, either due to tolerance from chronic conditions or patient abuse, or obesity. Studies have shown that obese patients may require more opioids for pain relief than would be suggested by their weight alone. A patient receiving the wrong dose of opioids (besides being an issue in itself) can also contribute. Issues have been raised regarding the difficulty in calculating doses with drugs of different potency, especially as patients move from one drug to another. Additionally, prescribing dose based on weight alone can result in a higher or lower dose than needed as the proper dose of opioids is subject to patient weight, age, sex, and tolerance level.
Issues with prescribing the wrong dose or wrong type of medication can occur when a patient or family member is responsible for the administration. Problems with medication administered by a provider typically occur around changes of the type or delivery method of the pain killer. Special care should be taken to recalculate the dose corresponding to any change in the drug dosage, type or delivery method. Similar-looking bottles and similar-sounding names are always a potential pitfall in proper drug administration and special care should always be taken in these cases.
Opioids reduce respiratory rate, which can result in respiratory depression. Respiratory depression can be impacted by other factors, such as a patient who is sleeping (most respiratory depression occurs during typical sleeping hours), or who is already pre-disposed to respiratory depression. This most commonly occurs with post-surgical patients (who may have residual anesthesia), old or young patients (who may be affected more greatly by the respiratory effects), patients who have abnormal respiratory control due to obstructive sleep apnea or morbid obesity, patients with supplemental oxygen and patients who have a self-administered drug delivery system, such as a fentanyl patch. Special care and monitoring should be taken with patients who have a higher risk level for respiratory depression.
However, monitoring for respiratory depression is difficult. Visually assessing respiratory depression (especially while a patient is sleeping or on supplemental oxygen) is extremely difficult. Using pulse oximetry can result in misleading values (including normal values while a patient is suffering from respiratory depression) and high false alarms. Because respiratory depression occurs gradually, intermittent monitoring may not be sufficient to pick up on a patient’s decline.
There is no one-size-fits-all solution for reducing respiratory depression. Rather, an individualized plan based on patient pain requirements and risk factors is shown to be the recommended way to reduce the risk of respiratory depression and ensure proper pain control for patients.
To view the Cause Map and recommended solutions, please click “Download PDF” above. Or learn more from The Joint Commission Sentinel Event Alert.