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Pain management and sedation

Overview

Analgesia and sedation

January 10, 2013
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Lessons Learned

Opioids’ Dangerous Sidekick: Benzodiazepines

August 11, 2016

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.

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Post

The Prince Effect
Spotlight on the Opioid Epidemic

June 10, 2016

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.

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Newsletter

Fentanyl Patch Use Guide Released

September 1, 2011

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.

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Newsletter

Error Identifying Anesthetic Agent

January 1, 2011

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.

  • Read the journal account
  • Read the newspaper story
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Post

Safe pain medication prescribing in emergency departments

October 22, 2013

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.

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Post

Reducing Controlled Substances Diversion in Hospitals
California Hospital Association Medication Safety Committee

May 16, 2013

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.

  • Download the document
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Post

Essential monitoring strategies to detect clinically significant drug- induced respiratory depression in the postoperative period
Anesthesia Patient Safety Foundation (APSF)

January 10, 2013

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.

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  • View article
Post

Risk Control Strategies for Reducing Patient Harm with HYDROmorphone
Reprinted with permission from the Institute for Safe Medicine Practices

January 9, 2013
  • 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
  • Read more
  • ISMP website
Post

FentaNYL transdermal patches — safe practices

June 21, 2012

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.

  • Download article
  • Read more

Medication safety

  • Pain management and sedation
  • Anticoagulation
  • General medication safety
  • Infusion pumps
  • Labeling and packaging
  • Small Bore Connectors
  • Storage

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September 12, 2012
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September 12, 2012
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September 12, 2012
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August 22, 2012
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Hospital Quality Institute
CHPSO is a division of the Hospital Quality Institute

July 11, 2014
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CHA & Regional Hospital Association members join CHPSO at no charge.

August 22, 2012
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Contact Info

California Hospital Patient Safety Organization
1215 K Street, Suite 800 Sacramento, CA 95814

August 22, 2012
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