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Study
Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.
June 23, 2021
Norris B, Soncrant C, Mills PD, et al. Jt Comm J Qual Patient Saf. 2021;47(8):489-495.
Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans Health Administration. The most frequent event type was medication administration error and the most frequent root cause was staff not following hospital policies or hospitals not having opioid-related policies.
