WWW Iowa Healthcare Collaborative

Narcotics


Case for Change

Medications are the most common intervention in health care and also most commonly associated with adverse events in hospitalized patients. According to the Institute of Medicine (IOM) report, Preventing Medication Errors, 1.5 million preventable adverse drug events (ADEs) occur each year in the United States and 400,000 adverse drug events that occur each year in hospitalized patients result in $3.5 billion in additional costs.

High alert medications are more likely to be associated with harm then other medications-they cause harm more commonly, the harm they produce is likely to be more serious and they have the highest risk of causing injury when misused. The harm leads not only to patient suffering but also to additional costs associated with the care of these patients.

The Institute for Safe Medication Practices (ISMP) has analyzed which medications cause serious harm and death. Six medications have been identified as so significantly risky in acute care settings that they have coined the term "high alert medications." ISMP has identified the following six medications as being the most dangerous: insulin, heparin, narcotics and opioids, injectable potassium chloride or potassium phosphate concentrate, neuromuscular blocking agents, and chemotherapy drugs. This toolkit will focus on narcotics and opioids.

This toolkit will:
  • Provide evidence based clinical guidelines on opioids and specific narcotics
  • Provide current narcotic policies and protocols
  • Increase provider education
  • Provide patient handouts
Sources:
  1. Nursing 2008
  2. Federico, Frank. (2007). Preventing Harm from High-Alert Medications, The Joint Commission Journal on Quality and Patient Safety, 33, (9), September, 537 - 542.


Tool Kit

Evidence Based Clinical Guidelines

General Narcotics

Adult Guidelines
Pediatric Guidelines
  • U.S. Pharmacopeia
    Error-Avoidance Recommendations for Medications used in Pediatric Populations

Specific Opioid Guidelines

Fentanyl Hydromorphone Meperidine (Demerol) Methadone Morphine Oxycodone



Policies, Procedures, and Protocols

Policies

Hydromorphone Policies Morphine Policies Protocols

Institute for Safe Medication Practices
This monograph on Patient Controlled Analgesia (PCA) will help identify common safety issues related to the use of PCA, design appropriate patient selection criteria for PCA use, develop standard PCA prescribing and monitoring practices, and communicate the need for an interdisciplinary approach to prevent patient harm.

Reflex Sympathetic Dystrophy Syndrome Association
Opioid Treatment Protocol.



Forms

Opioid Consent Forms

American Academy of Pain Medicine
Consent for Chronic Opioid Therapy
  1. English
  2. Spanish

Cass County Health Systems, Atlantic, IA
Drug Management Agreement.

Cass County Health Systems, Atlantic, IA
Long-term controlled substances therapy for chronic pain agreement.



Educational Materials

Physician Education

Educational Information
Patient Education

Handouts
  • Pain Treatment Topics
    "Patient Instructions" handouts on the safe use of oxycodone. (available in English and Spanish)



Other

Federal Regulations

American Academy of Pain Medicine Research on Electronic Narcotic Prescriptions

Journal of Patient Safety




Success Stories

Reduction of Opiate Related Adverse Drug Events at Duke University Hospital

http://www.ihi.org/IHI/Programs/Campaign/mentor_registry_ham.htm

The Pain Management Oversight Committee (PMOC) and Six Sigma Oversight Committee (SSOC) collaborate to improve the safety of patients receiving pain management interventions. At their direction, a dynamic multi-disciplinary team that included advanced practice nurses (APNs), pharmacists, physicians and staff nurses was established to identify the focus of a Six Sigma medication safety project. Analysis of the voluntarily reported ADE reports revealed that the initial focus should be on opiate-related ADEs and, more specifically, on patient controlled analgesia (PCA) in the post-operative period. The team's goal was to reduce the occurrence of ADEs resulting in harm to patients using PCA. Of particular concern were instances of respiratory depression. Further drill down on the data led to a focus on orthopedic patients. The group assessed issues related to prescribing, administering, and monitoring of opiate medications when analgesia is controlled and administered by the patient. The ultimate goal was to error proof the process, to ensure that whoever is involved, no adverse events occur. In order to properly evaluate the process, a global look from pre-op screening to the OR to the PACU, to the patient stay on the unit was needed.

A number of "just do it's" were identified and implemented. These included eliminating extension tubing on all PCA lines, placing patient & family caution labels regarding use of the PCA activation button on the PCA machine, and the addition of a label to the PCA pendant with a stoplight that states "Caution: Only the patient can press the PCA button." The team also focused on setting realistic expectations for the patients and family members. The previous pain management slogan was "Healing Doesn't Have to Hurt," and, as a result, patients expected to not experience any pain. The pain program and PMOC designed a new slogan: "Managing your Pain. Caring for your Safety." The team developed informational flyers that are distributed in the pre-op screening clinic, during the pre-op class, and on the patient care floor. In addition, lapel pins were made displaying the slogan with a scale graphic and are worn by pain management providers.

Nursing knowledge of opiates and their management was also an area for improvement. The pain management APNs provided intense staff nurse education. In addition to didactic education, they provided individual coaching and competency checks. The APNs' focus was on critical thinking on the individual patient's pain management history and the medication to be administered. They also prepared the nurses to educate patients about safe pain management and reasonable pain expectations. A patient education sheet was developed to re-enforce these concepts. This was produced in English and Spanish as Duke has a substantial Hispanic patient population. After the "just do its" the Six Sigma team worked to develop a plan of action to error proof the system. A prospective Healthcare Failure Mode and Effects Analysis (HFMEA) was conducted to analyze the process and identify potential failure points. To simplify the effort, the team split in to two working groups: one focused on prescribing and another focused on administration/monitoring. The Veterans Affairs HFMEA model was followed and resulted in the identification of 134 failure modes for prescribing and 219 failure modes for administration and monitoring. The next step was to identify solutions for each of these failure modes.

Error proofing is the ultimate goal and generation of solutions that eliminate, replace, facilitate, detect or mitigate have been proven to demonstrate the best return on investment. To reduce the overwhelming number of solution recommendations, a systematic approach to prioritizing the order for implementation was developed with the help of error proofing experts from the North Carolina State University. This methodology narrowed the number of critical solutions to be implemented from 278 to 30. Examples of recommendations are: communication of critical risk factors through the continuum of care, standardization of opiate concentrations, post-anesthesia care unit (PACU) summary sheet of opiates given in pre-op holding, the OR and PACU, and revision of the current PCA form to include lean body weight, contraindications for morphine PCA including end stage renal disease, and critical risk factors.

The critical risk factors are those characteristics or diagnoses known to increase the risk of respiratory depression in patients using PCA. Assessment of the past adverse drug events revealed that the first twenty-four hours post-operatively was the critical time period for respiratory depression. As a result, nursing assessment of the patient's respiratory status was increased to every two hours during the first 24 hours of PCA use from every 4 hours. This assessment also increases following an increase in the PCA dose.

Prior to this project there were a number of serious PCA-related errors on the orthopedic surgical unit. Since June 2004, on this unit, there has been a 50% decrease in reported events resulting in harm to a patient related to a PCA. As a result of team efforts, in each of these instances, the staff nurses recognized the concerns early and intervened to reduce harm. In addition, prior to the standardization of the adult PCA concentrations, 25% of the PCA events were related to concentration errors. After the standardization to one concentration per drug, the events associated with a PCA concentration have been reduced to 6.8%. Morphine PCA use with end stage renal disease patients has also decreased housewide since the implementation of the new PCA order form on March 1, 2005. As of May 2007, these improvements have been sustained. The opiate oversight implementation team will continue to meet until all recommendations have been implemented in all areas of Duke University Hospital and opiate ADEs resulting in harm to patients have been reduced by 50% from baseline. The lessons learned from this Six Sigma project have been and are being translated to areas throughout the hospital where PCAs are used.

This project and its positive impact on patient safety is a single example of error proofing efforts at Duke University Hospital. The hospital maintains several patient safety indicators on its balanced scorecard with performance targets that are well defined. The goal is to eliminate preventable adverse drug events that reach the patient. This project is one step in that direction.




Mentors

Please contact IHC if your organization would like to contribute materials to this tool kit.


Resources

American Academy of Pain Medicine
Institute for Healthcare Improvement
Institute for Safe Medication Practices


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    Information that discusses how to better communicate medical information to patients.

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    Information on the monitoring and reporting of HAIs.

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    Details on the principles and components of a patient centered medical home, including the business case and how to become one.

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    Resources for providers to avoid adverse drug events.

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    Resources for the safe administration of narcotics and opioids.

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    Information and resources for providers in their efforts to assist patients with tobacco cessation.

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