Preventing Iatrogenic Opioid Overdose in the ED

Opioids are a mainstay of ED therapy and also a common culprit in iatrogenic medication errors. In most cases involving such errors, the patient’s presenting medical complaint was not life-threatening; however, the opioid administration led to a near-fatal event. These errors are generally predictable and avoidable.

The Study: “Preventing Iatrogenic Overdose: A Review of In-Emergency Department Opioid-Related Adverse Drug Events and Medication Errors” was a retrospective study conducted in 2 urban academic EDs over a 3 year period. 87 patients were identified through an EMR search for naloxone administration following an opioid analgesic order. 51 of these were found to have a preventable Adverse Drug Event (ADE) due to opioid administration. A three-person panel consisting of a clinical pharmacist, ED physician, and ED physician-toxicologist reviewed the cases and conducted a root cause analysis to determine factors related to harm. 84.3% of patients in the study were found to have suffered harm, most commonly hypoxia that required supplemental oxygen. They then developed possible solutions to avoid future errors.

Patients who are most at risk for harm from an opioid medication are elderly, altered, demented, intoxicated, obese, or have comorbidities such as COPD, renal impairment, hepatic impairment, and sleep apnea. Renal impairment leads to reduced drug excretion. Hepatic impairment results in decreased first-pass metabolism as well as increased volume of distribution due to lower levels of drug-binding proteins. Hydromorphone was implicated twice as often as morphine, likely related to its high-potency as well as differences in its onset and duration of action. Multiple doses, mixing opioids, or co-administation of other sedating medications were also identified in patients who experienced ADEs.

STUDY RESULTS (highlights)

Blog post by: Dr. Wendy Chan

Reviewed by: Dr. Ian deSouza

WORKS CITED:

Beaudoin, Francesca L., Roland C. Merchant, Adam Janicki, Donald M. Mckaig, and Kavita M. Babu. “Preventing Iatrogenic Overdose: A Review of In–Emergency Department Opioid-Related Adverse Drug Events and Medication Errors.” Annals of Emergency Medicine 65.4 (2015): 423-31. Web.

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wendyrollerblades

Senior EM Resident at SUNY Downstate / Kings County Hospital, EM/Critical Care Blogger, Medical Student Education Curriculum Co-Chair, has a blackbelt in "keepin' it real"

Latest posts by wendyrollerblades (see all)

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