Opioids were the most commonly mentioned drug class among the CHPSO database. Of all the medication incident reports submitted to CHPSO, opioids were mentioned in 62,157 reports. The second most common drug class was benzodiazepines and non-benzodiazepine hypnotics, with 23,508 reports. Although this is a large drop off from opioids, benzodiazepines/hypnotics should not be overlooked as a source of potential harm.
The following are representative cases from the CHPSO database:
A patient requested a dose of an opioid. The nurse refused as she believed it was unnecessary. The patient became irate with the nurse and physically aggressive towards her. A code gray was called.
The document High Alert Medication Guideline — FentaNYL Transdermal Patch, developed by the California Hospital Association’s Medication Safety Committee, summarizes strategies to reduce preventable harm to patients in the hospital setting.
This report details an error by an inexperienced pharmacist committed when handling easily confused medications with similar drug names. One patient’s death at this major teaching hospital was ascribed to the inadvertent drug swap. The event shook the self-confidence of those at the institution and was broadly covered in the popular press.
In an effort to reduce death and addiction due to prescription drug abuse, a set of guidelines and other resources for emergency departments to use have been released.These guidelines are a collection of recommendations developed by the San Diego County Medical Society (SDCMS) Prescription Drug Abuse Medical Task Force, a group that includes representatives from Imperial County as well. They draw on published medical literature and the experience of various groups across the country.
The attached road map is intended for acute care settings as a plan to help navigate controlled substance diversion prevention goals. The document provides a recommended framework to coordinate the needed resources and technology for an optimal diversion prevention program. Actions taken pursuant to this framework should be reflected in a standardized set of processes within the organization to ensure that they are maintained.
These Conclusions and Recommendations are intended to facilitate detection of clinically significant drug-induced respiratory depression in non-ambulatory adult patients receiving parenteral opioids for management of acute postoperative pain while being cared for in a healthcare facility.
Differentiate HYDROmorphone from morphine where both products are available (use tall man lettering on labels, order sets, order entry screens, medication administration records, etc.)
Include the brand name Dilaudid on order sets, order entry screens, medication administration records, etc., to help differentiate HYDROmorphone from morphine
Limit the number of strengths available (e.g., do not stock HYDROmor
The document High Alert Medication Guideline — FentaNYL Transdermal Patch, developed by the California Hospital Association Medication Safety Committee, summarizes safer practices to reduce the preventable harm to patients in the hospital setting.
