Sentinel Event Alert on the Safe Use of Opioids and How IT Can Help
On August 8, The Joint Commission released a Sentinel Event Alert titled “Safe use of opioids in hospitals.” Sentinel events are unexpected occurrences involving death, serious injury, or the risk thereof. Hospitals must immediately investigate and respond to sentinel events, and The Joint Commission reviews organizations’ responses to sentinel events as part of its accreditation surveys. Periodically The Joint Commission issues Sentinel Event Alerts – newsletters that identify specific types of sentinel events, their common causes, and suggested steps for preventing future occurrences.
The Alert issued earlier this month, the 49th Alert issued since their inception in 1998, and the first issued in 2012, focuses on opioids – a class of drugs frequently associated with adverse drug events. Providers are warned that patients at greatest risk for oversedation or respiratory depression include patients who are obese, patients who present with sleep apnea, and patients who may have a history of analgesic use, abuse, tolerance issues, or current use. The recommended actions in the 5-page Alert are exhaustive and include monitoring carbon dioxide levels as opposed to (or in addition to) pulse oximetry, employing PCA technology to reduce the risk of oversedation, and investing in policy and procedure review/development along with education and training as required.
In the opioid-related adverse events reported to The Joint Commission’s Sentinel Event database between 2004 and 2011, 47% were wrong-dose medication errors. To that end, the Alert specifically recommends that healthcare organizations use HIT to, “Build red flags or alerts into e-prescribing systems for all opioids. The red flags can be either for dosing limits or alerts, or for verifications.” HIT professionals should expect to be approached by compliance and safety personnel if their e-prescribing systems are not presently configured support the actions suggested by The Joint Commission.
The Sentinel Event Alert is very clear that its recommendations are limited to opioid use among hospital inpatients. Opioids are also used extensively with patients suffering from chronic pain – ambulatory usage that is doubling every three to four years. A comprehensive resource for healthcare providers is the Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, developed by the Department of Veterans Affairs and the Department of Defense. A recommended practice for patients undergoing chronic opioid therapy is that those patients execute agreements that both educate patients on opioid therapy and document acknowledgement of their responsibilities. Again, HIT can play a role in this area. Some VA Medical Centers have automated the process for documenting patient participation in opioid therapy. That strategy was presented recently at the 23rd IHI National Forum, a major patient safety conference.
Opioids are generally safe and these drugs are essential to managing pain for hospitalized patients as well as for treating chronic pain in ambulatory patients. Healthcare organizations should review their policies and procedures for the use of opioids in light of the suggestions contained in The Joint Commission’s most recent Sentinel Event Alert.
Tim Kelly serves as a vice president for Dialog Medical, a Standard Register company.