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- Communication Improvement 3
- Culture of Safety 1
- Education and Training 4
- Error Reporting and Analysis 7
- Human Factors Engineering 5
- Legal and Policy Approaches 2
- Logistical Approaches 2
- Policies and Operations 2
- Quality Improvement Strategies 4
- Specialization of Care 3
- Technologic Approaches 4
- Device-related Complications 2
- Diagnostic Errors 1
- Drug shortages 1
- Medication Errors/Preventable Adverse Drug Events 8
Search results for "Opiates/Narcotics"
- Newspaper/Magazine Article
Bartolone P. Kaiser Health News. March 16, 2018.
Drug shortages may require clinicians, pharmacists, and hospitals to divert from standard processes to address gaps. This news article reports how reduced opioid production as an approach to address the opioid crisis has led to shortages and subsequent patient harm, such as insufficient pain management for surgical, cancer, and trauma patients.
Daley J. Colorado Public Radio. February 23, 2018.
Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.
William Brangham. PBS News Hour. September 29, 2017.
Bendix J. Med Econ. September 25, 2017.
The persistent problem of opioid-related harm calls for changes in pain management practices and system processes in all care settings. This magazine article reports on ways physicians can help proactively recognize and address the potential for patient opioid misuse, such as adherence to guidelines and monitoring patient opioid use. An Annual Perspective discussed the opioid crisis as a patient safety problem.
R3 Report. 2017 Aug 29;11:1-7.
Carr S. ImproveDx. April 2017;4:1-4.
Hoffman J. New York Times. June 10, 2016.
Overprescribing of opioids for pain management contributes to the growing crisis involving opioid-related harm. This newspaper article reports on one hospital's efforts to avoid opioid use for patients presenting to the emergency department with pain. Alternative treatments included nonnarcotic infusions, nitrous oxide, music therapy, and holistic techniques.
Stempniak M. Hosp Health Netw. March 2, 2016.
Inappropriate prescribing behaviors can contribute to opioid misuse. Discussing the opioid epidemic in the United States, this magazine article highlights proactive efforts to stem the problem (such as best practices for prescribing and administering opioids for patients with chronic pain) and treatment strategies for patients who are addicted to these high-risk medications.
ISMP Medication Safety Alert! Acute Care Edition. August 8, 2013;18:1-4.
Relating how an infant died after ingesting a medication patch, this newsletter article advocates for clinician and organizational engagement in educating consumers about risks.
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, and reduce adverse events.
Feldman D, Moore K. KING TV. Seattle, WA. October 14, 2009.
This news story reports on the death of a pediatric patient after he was mistakenly prescribed fentanyl for pain management following a dental procedure. The hospital disclosed the error and has publicly apologized.
ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.
This article provides screening, dosing, and monitoring recommendations for using basal opioid infusions and patient-controlled analgesia (PCA) in patients at risk for developing respiratory depression.
ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
This article reports on an overdose caused by improper label placement on a patient controlled analgesia (PCA) pump and provides recommendations for preventing pump-related medication errors.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2008;13:1-3.
This article describes errors that can occur when methadone is prescribed for pain and offers safe practice recommendations for the use of this medication.
ISMP Medication Safety Alert! Acute Care Edition. June 28, 2007;12:1-3.
This article discusses inappropriate prescribing of medication patches for acute pain management and provides strategies for minimizing problems associated with their use.
ISMP Medication Safety Alert! Acute Care Edition. February 22, 2007;12:1-3.
This article lists common risks associated with opiates, a high-alert medication, as well as recommended safety improvements to reduce these risks.
ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.
This article describes dosing errors associated with improper concentration programming of patient controlled analgesia (PCA) pumps and provides recommendations for preventing future errors.