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.
