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TJC issues sentinel alert on opioid dangers

by Brendon Nafziger, DOTmed News Associate Editor | August 08, 2012
The Joint Commission issued a sentinel alert Wednesday advising hospitals to beef up training programs to prevent sometimes deadly opioid dosing errors and other adverse events among hospital inpatients.

The alert comes a few months after the Senate Finance committee announced it was investigating a number of pharmaceutical manufacturers and medical groups, including TJC, about whether they “promoted misleading information” about opioids while getting financing from drug makers.

While drugs like fentanyl, oxycodone and morphine are known for their abuse potential, TJC said in its alert that opioids are also among the drugs most commonly linked to adverse events among hospital patients, often because of inadvertent overdosing, dangerous interactions with other drugs, or inadequate patient monitoring, the group said.
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Dosing errors were the leading culprit, however. Nearly half (47 percent) of all opioid-related adverse events reported to TJC were caused by wrong dose flubs, according to seven years' worth of data from the accrediting organization's sentinel event database.

Common adverse events from the pain-relieving drugs include nausea, delirium, constipation, falls and sedation, but the deadliest risk is respiratory depression.

About one in 200 post-op patients can experience respiratory depression, TJC said in its alert. Patient risk factors include having sleep apnea, being obese, taking other sedatives and receiving higher opioid doses.

To improve the safety of opioid therapy delivery, TJC put forward a four-point plan, including using better standardized risk tools, such as the Pasero Opioid-Induced Sedation Scale; improving training for clinicians, staff, patients and their caregivers on opioid risks; investing in smart pumps, e-prescribing and conversion support systems to prevent medication errors; and creating better processes for staff to follow, such as instructing providers not to rely solely on pulse oximetry for oxygenation, because it can give misleading results for patients experiencing respiratory depression.

Senate investigation

In May, Senate Finance Chair Max Baucus (D-Mont.) and committee member Chuck Grassley (R-Iowa) wrote a letter to TJC, asking for more information about any financial ties to opioid manufacturers. In particular, the group wanted to know about its relationship with Purdue Pharma, the original makers of Oxycontin (oxycodone). A 2003 Government Accountability Office report said Purdue funded some TJC pain management programs, likely helping to give it access to hospitals.

The letter was one of about 10 that the senators sent to drug companies and health care organizations to understand the links between them.

"Doctors and patients should know if the medical literature and groups that guide the drugs’ use are paid for by the drugs’ manufacturers and if so, how much," Grassley said in a statement. "Education on the proper use of pain medication is a key step in preventing abuse and misuse, so it’s important to understand what material is out there.”

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