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Joint Commission Issues New Sentinel Event Alert: Safe Use of Opioids in Hospitals

August 8, 2012
By: Elizabeth Eaken Zhani, Media Relations Manager


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(OAKBROOK TERRACE, Ill. – August 8, 2012) Although hospital patients may need the strong pain relief that only opioids can provide, a Sentinel Event Alert  issued today by The Joint Commission urges hospitals to take specific steps to prevent serious complications or even deaths from opioid use.

Opioid analgesics rank among the drugs most frequently associated with adverse drug events. Research shows that opioids such as morphine, oxycodone and methadone can slow breathing to dangerous levels, as well as cause other problems such as dizziness, nausea and falls. The reasons for such adverse events include dosing errors, improper monitoring of patients and interactions with other drugs, according to The Joint Commission’s Sentinel Event Database. Reports also show that some patients, such as those who have sleep apnea, are obese or very ill, may be at higher risk for harm from opioids.

“Assessing and managing pain is critical to patients who otherwise would suffer, but avoiding the harm that accompanies the adverse effects of powerful opioid analgesics is equally important.  Hospitals should educate staff about the evidence-based actions recommended in this Alert,” says Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., president, The Joint Commission. “Accidental opioid overuse in the hospital is absolutely preventable. Information in this Alert will help doctors and nurses keep patients safe.”

The Joint Commission Alert recommends that health care organizations take the following actions:

  • Implement effective practices, such as monitoring patients who are receiving opioids on an ongoing basis, use pain management specialists or pharmacists to review pain management plans, and track opioid incidents.
  • Use available technology to improve prescribing safety of opioids such as creating alerts for dosing limits, using tall man lettering in electronic ordering systems, using a conversion support system to calculate correct dosages and using patient-controlled analgesia (PCA).
  • Provide education and training for clinicians, staff and patients about the safe use of opioids.
  • Use standardized tools to screen patients for risk factors such as oversedation and respiratory depression.

The Joint Commission Alert also includes details about respiratory depression risk factors and offers information relevant to opioid risks and safety. The Joint Commission sought input for the Alert from experts across the United States, including the Cancer Pain Program at Northwestern University’s Feinberg School of Medicine, the University of Wisconsin Hospital and Clinics, the Hackensack (N.J.) University Medical Center and the University Medical Center in Tucson, Arizona.

The warning about risks associated with opioids is part of a series of Alerts issued by The Joint Commission. Previous Alerts have addressed health care worker fatigue, diagnostic imaging risks, violence in health care facilities, maternal deaths, health care technology, anticoagulants, wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on The Joint Commission website.

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