Learning from e-Safety Reports: Opiod Analgesics

Improving Patient Safety
Patti Cornish, Sandra Knowles, and Dr. Ed Etchells, Patient Safety Service

Opioids, also known as narcotic analgesics, (e.g., morphine, HYDROmorphone, oxycodone, fentanyl) are high-alert drugs, because there is an increased risk of harm when they are used in error. Errors are not necessarily more common with high-alert drugs than other drugs, but when they occur, the consequences are potentially more devastating.
The pharmacists with the Patient Safety Service review all e-Safety reports involving medication and look for trends. Information from Sunnybrook’s e-Safety Reporting system from the past 9 months indicates that medication incidents involving opioid analgesics are commonly reported. Opioid analgesics constitute the largest single category of drugs involved (i.e., 15% of all reports).

Fortunately, the vast majority of opioid errors at Sunnybrook from Jan-Sep 2008 were not associated with any significant harm; in only 7% of the incidents was the harm listed as moderate or severe at the time of the report. In terms of specific opioids mentioned in the e-Safety reports, the breakdown was as follows: hydromorphone – 31%; morphine – 26%; oxycodone/OxyCONTIN® - 23%; fentanyl – 7%; and others – 13%.
This newsletter is intended to highlight three commonly reported errors with opioids and provide some suggestions for safety improvements.
Confusion between HYDROmorphone and Morphine

Case: A 93-year-old female patient was ordered morphine 2 mg subcutaneously q4h prn post-operatively. Both HYDROmorphone 2 mg/1 mL vials and morphine 2 mg/1 mL ampoules were stocked in the narcotic drawer on the patient care unit. On one occasion, HYDROmorphone 2 mg was inadvertently selected from the narcotic drawer and administered to the patient instead of morphine 2 mg. Shortly thereafter, the patient seemed unusually groggy and the error was identified. The physician was informed and the patient was closely monitored for several hours – vital signs remained stable and the patient recovered completely.

Mix ups between HYDROmorphone and morphine are common and potentially serious errors. Although in this situation the patient recovered, confusion between these two drugs can be fatal. A high-profile error occurred several years ago at an emergency department of a hospital in Alberta where a 69-year-old patient received HYDROmorphone 10 mg intramuscularly instead of 10 mg of morphine. The patient was discharged from the emergency department shortly after the drug had been administered, deteriorated on the drive home, arrested and died at another rural Alberta hospital.

HYDROmorphone is a very potent opioid – it is generally considered to be at least five times more potent than morphine, meaning that a dose of 10 mg of HYDROmorphone is equivalent to at least 50 mg of morphine. Over the past decade, the role of HYDROmorphone in acute and chronic pain management has been increasing. HYDROmorphone is often used when patients are unable to tolerate the adverse effects of morphine. As well, HYDROmorphone is becoming increasingly preferred for use in elderly patients or those with renal or hepatic impairment. As a result of this more extensive usage, the availability of HYDROmorphone in patient care areas has been necessarily increased, enhancing the potential for errors and confusion with morphine.
There are several important factors that contribute to the risk of substitution errors with HYDROmorphone and morphine:
The drug names both look-alike and sound-alike.
Both HYDROmorphone and morphine injections are available in the same strengths – i.e., 2 mg/1 mL and 10 mg/1 mL. For the oral dosage forms of these drugs, the strengths are different; however, substitution errors are also reported with the oral products.
Lack of familiarity with HYDROmorphone (some of the reported mix-ups have been due to the mistaken belief that HYDROmorphone is a generic or chemical name for morphine).

Over the past few years, several strategies have been implemented at Sunnybrook to safeguard the use of HYDROmorphone. First and foremost, the high concentration injectable formats of HYDROmorphone (i.e., ≥ 10 mg/1 mL) have been eliminated as much as possible from patient care areas (exceptions include palliative care, oncology, intensive care). Our Sunnybrook "in-house" drug labels and narcotic documentation records use TALLman lettering to emphasize the "HYDRO" portion of HYDROmorphone, to help distinguish it better from morphine. Despite these strategies, there is still an ongoing risk of substitution errors with HYDROmorphone and morphine and further attention to this problem is required. Referring to HYDROmorphone by its traditional brand name "Dilaudid®" to reduce name confusion with morphine has been considered. However, the availability of several generic HYDROmorphone products makes this strategy problematic to implement.
The following safety tips are simple improvements that can be employed in any patient care area to further minimize the risk of errors with these opioids.
Safety Tips to Reduce the Risk of Errors with HYDROmorphone and Morphine
1. Ensure that staff is familiar with the difference between HYDROmorphone and morphine – i.e., HYDROmorphone is five times more potent than morphine. [a pocket card on equianalgesic doses of opioids is available from Pharmacy and also on SunnyNet: http://sunnynet/data/pharmacy/htdocs/misc/Opioid_Dose_Equiv_Card.pdf]

2. In narcotic storage areas, segregate HYDROmorphone from morphine injection (e.g., place in separate compartments of the narcotic drawer, store on different shelves in the narcotic cupboard).

Outer Packaging
Morphine Ampoule and HYDROmorphone Vial
3. If high concentration HYDROmorphone injection (10 mg/1 mL) is issued to a patient care area to meet the needs of a specific patient, ensure that it is returned to pharmacy as soon as the patient is discharged or no longer requires it.

4. Always read back telephone or verbal orders to the prescriber to ensure that you have heard the correct drug name. If needed, ask for clarification by using HYDROmorphone’s brand name (e.g., Do you mean Dilaudid®?).

5. Consider the role of an independent double-check before administration of injectable opioids. [see link to Sunnybrook’s procedure for independent double-checks: http://sunnynet/Default.aspx?cid=100865&lang=1]

6. When implemented, Computerized Provider Order Entry (CPOE) will help to reduce the risk of errors at the time of ordering by including TALLman lettering for all HYDROmorphone entries, accompanied by the brand name "Dilaudid®".
Confusion between Short- and Long-Acting Oral Opioid Analgesics
Sustained release (long-acting) oral formulations of opioid analgesics are designed to deliver the medication gradually over an 8- or 12-hour period. This compares to immediate-release (short-acting) opioid analgesics that require doses to be administered every 2 to 4 hours. When properly used, long-acting opioid analgesics provide a decrease in frequency of administration, longer periods of consistent pain control and may lower the incidence of adverse effects. Short-acting opioid analgesics are often used in conjunction with long-acting opioids to help manage breakthrough pain. Unfortunately, confusion may occur between the long- and short-acting formulations of opioid analgesics, especially when they contain the same drug in the same dose. Although most medication error reports document confusion with short- and long-acting formulations of oxycodone (i.e., oxycodone and OxyCONTIN®), there have also been reports with HYDROmorphone (HYDROmorphone and Hydromorph CONTIN®) and morphine (Statex® and MS CONTIN®, M-Eslon®).
When a long-acting opioid analgesic is inadvertently substituted for a short-acting preparation, this can potentially result in accumulation of the opioid analgesic leading to toxicity. For example, a patient was ordered short-acting oxycodone 10 mg orally every 2 hours when needed. The long-acting product (OxyCONTIN® 10 mg) was selected in error and several doses were administered every 2 hours because the patient was not experiencing adequate pain relief. This is explained by the fact that OxyCONTIN® slowly releases the drug for absorption and peak blood levels are not achieved for several hours. After 8 to 12 hours, the patient became excessively sedated due to the cumulative effect of repeated doses of OxyCONTIN®. The error was recognized and the patient recovered completely.
Conversely, when a short-acting opioid analgesic is accidentally substituted for a long-acting preparation, this may result in excessive opioid effects initially, followed by lack of pain control later in the dosing interval. For example, a patient was scheduled to receive a long-acting product, Hydromorph CONTIN®, 12 mg orally every 12 hours. Inadvertently, immediate-release HYDROmorphone 12 mg was given. Since the immediate-release preparation is formulated to release HYDROmorphone rapidly and provide analgesia over a 3 to 4 hour period, the patient experienced excessive sedation within one hour of administration, followed by the need for breakthrough medication in the last half of the dosing interval due to inadequate pain control.
Confusion between the short- and long-acting formulations of opioid analgesics may be the result of several contributing factors including:
Lack of awareness of the differences between the immediate- and sustained-release formulations of opioid analgesics. At Sunnybrook, a Table outlining the characteristics of commonly used oral narcotic preparations (the "pink sheet") is available in every narcotic binder.
Similarity between the names of the various preparations (e.g., oxycodone and OxyCONTIN®; HYDROmorphone and Hydromorph CONTIN®). At Sunnybrook, all long-acting opioid formulations that are packaged "in-house" have fluorescent pink labels and auxiliary stickers ("long-acting") attached to the package. (see photos in Figure 2)
Figure 2: Oxycodone Immediate-Release and Sustained-Release (OxyCONTIN®) Packaging
Safety Tips:
1. Physically separate short- and long-acting preparations of opioid analgesics in the narcotic storage area (e.g., place in different compartments of the drawer or store on separate shelves in a cupboard).

2. Understand the differences between short- and long-acting products; short-acting formulations are typically administered every 2 to 6 hours and long-acting products are administered no more frequently than every 8 to 12 hours. [see link to document on oral opioid products: http://sunnynet/data/pharmacy/htdocs/misc/Opioid_Oral_Products_Table.pdf]

3. Never crush or allow patients to chew long-acting products – this will destroy the sustained-release properties of the product.

4. When implemented, Computerized Provider Order Entry (CPOE) will help to reduce the risk of ambiguous orders by using full drug names and clearly designating which products are sustained-release. As well, CPOE will include default dosing options to ensure that immediate- and sustained-release products are ordered at appropriate intervals.
Fentanyl Patches: Caution Needed
There have been several patient deaths linked to inappropriate prescribing of the fentanyl patch in opioid-naïve patients despite warnings from Health Canada, the US Food and Drug Administration and the pharmaceutical manufacturer. Luckily we have not had a reported serious adverse event at Sunnybrook, although numerous medication incident reports highlight issues surrounding the use of the fentanyl patch.
Case: A 65-year-old woman with a history of osteoarthritis of the right knee underwent a right total knee replacement. Prior to surgery, she was on NO regular opioid pain medication. Post-op, her pain was well managed with oxycodone, gabapentin and acetaminophen, although she experienced severe nausea and vomiting in addition to extreme drowsiness. Her gabapentin was discontinued and her long-acting oxycodone (OxyCONTIN®) dose was reduced from 20 mg every 8 hours to 5 mg every 8 hours over a three-day period, supplemented with short-acting oxycodone for breakthrough pain.. Despite these changes, the nausea and vomiting continued and the patient refused further OxyCONTIN® doses. On the weekend, the patient was started on fentanyl patch 50 mcg to be applied every 3 days in order to maintain pain control and to possibly reduce her nausea and vomiting. Concern was raised by an RN due to:
Inappropriate use of the fentanyl patch: the fentanyl patch is not recommended for relief of post-op pain
Inappropriate dose: on the previous day, the patient had received a total oxycodone dose of 45 mg (equivalent to 75 mg of morphine) which translates to a 25 mcg fentanyl patch (not 50 mcg as prescribed)
The fentanyl patch was discontinued two days later. Luckily, the patient did not develop any adverse effects from this event.
Fentanyl patches contain a very strong opioid and it is imperative that the following best safety practices be followed in the prescribing and use of this product:
• Fentanyl patches should NOT be used for the management of short-term, acute or post-op pain. Non-tolerant patients may develop respiratory depression, potentially leading to death.
• Fentanyl patches can be used for the management of persistent, chronic moderate to severe pain. They should ONLY be considered for use in adults who have already been receiving opioid therapy for a minimum of one week at a total dose of at least 60 mg/day oral morphine or equivalent. (A fentanyl patch of 25 mcg/hour is equivalent to approximately 60 to 130 mg of oral morphine per day).
• Fentanyl patches are intended for use in patients who require continuous (around the clock) opioid administration for an extended period of time.
• Fentanyl patches are generally administered every 3 days. It is important that the previous patch be removed at the time of application of a new patch since there is enough residual drug remaining in the old patch to potentially cause harm.
• A heat source should NOT be applied to the patch (e.g., heating pad, hot water bottle) as this can result in increased and/or faster release of fentanyl from the patch.
• Used patches contain residual drug and most be disposed of safely.
Correct disposal of used patches in hospital: fold the sticky sides together and dispose of in the sharps containers.
Correct disposal of used patches in the community: fold the sticky sides together and flush the used patch down the toilet.
• Fentanyl patches are available as 12, 25, 50, 75 and 100 mcg/hour patches. Cutting of the patch to accommodate unusual doses must NOT be done as this can result in leakage and uncontrolled release of the medication.
Safety Tips:
1. Fentanyl patches should only be used in patients who have been on a stable dose of an opioid analgesic (e.g., morphine, oxycodone, hydromorphone) for a minimum of one week.

2. Never cut fentanyl patches.

3. Always remove the previous fentanyl patch before applying a new one.

4. Dispose of used fentanyl patches in the sharps container (NOT the regular garbage).
The Patient Safety Service would like to thank Mona Sawhney of the Acute Pain Service at the Holland Centre for reviewing this newsletter.

ACLS course for RN's

ACLS COURSE For RNs

MARCH 6-8, 2009

AT SUNNYBROOK HEALTH SCIENCES CENTRE
Fri. 5:30 p.m.-8:30 p.m.

Sat. 8:30 a.m.-4:00 p.m.

Sun. 9:00 a.m.-12 Noon
________________________________________________________________

This is a Regular Weekend ACLS Certification Course, exclusively for RNs.

To Register, please contact Terry G. Smith in the ACLS office.
Online information and Registration is available.

Email: terryg.smith@sunnybrook.ca
Telephone: 416-480-4943 Office: Room H-265

FEES: $360.00, payable by cheque made out to “Sunnybrook Hospital”.
(Fee includes the current edition of the ACLS Provider Manual,
Instructional CD and Pocket Cards)
Ask your department head about re-imbursement.

SIGN-UP SOON AS SPACE IS LIMITED


REGISTRATION FORMS AND FEES MUST BE SUBMITTED BY
FRIDAY FEBRUARY 13, 2009

Strategic Balanced Scorecard

Here is information regarding The Strategic Balanced Scorecard that I'm sure will give you an idea of all of the objectives Sunnybrook has and how Sunnybrook is performing. The public also has access to this website.

"Welcome to Sunnybrook’s Strategic Balanced Scorecard. The purpose of this site is to give you an electronic window on the hospital to see how we are doing in meeting our eight strategic goals that were established in our 2006 Strategic Plan. You can view our strategic goals by selecting the "Strategic Model" link above. Each of our eight strategic goals has a number of objectives and indicators, and in this site you will be able to see how Sunnybrook is performing in the dimensions of: quality of patient care, research and teaching, and sustainability and accountability. We encourage you to explore this interactive version of our Strategic Balanced Scorecard to obtain the most out of information we are providing.

Download theprintable report

While viewing our results, if you see a target we have not met, please click on the bar in that specific chart to learn about our action plan to improve.Our Strategic Balanced Scorecard provides an unprecedented level of transparency for our communities. We believe it is important for the many communities we serve across the province to see how we are meeting their needs to deliver excellent care, conduct innovative research, and offer rewarding educational experiences. We are providing this information in an easy to understand format with written explanations, and in many cases, our staff and physicians provide video clip messages along with the various measurements.Since we are reporting on Sunnybrook’s Goals and Objectives, not all of this information is directly comparable with what other hospitals have chosen to report on their balanced scorecards. We plan to update this information twice a year and you should generally expect to see gradual advancement towards our targets. We hope you find this site useful. If you have any questions or would like to contact us about any of the information contained here please contact us via the email at questions@sunnybrook.ca
We thank you for taking the time to visit our webpage. "

Question & Answers 'Seton's'

A question was asked by Rose D from Same Day Surgery regarding Setons as they have been seeing these procedures done on patients who have rectal fistulas. I posed the question to the surgeon performing these procedures and also asked her to look over an article I found on-line. Routine Use of Setons for the Treatment of Anal Fistulae

According to Dr. F, "they are a comfortable loosely placed soft small piece of material that is no maintenance. It really doesn’t require discharge teaching in Same Day. I review everything with the patients in the office. I just looked at the picture (see article) you have. I use a softer material and it is never left with long ends….most patients hardly notice it is there…but this is the principle.
The seton is a drain that is placed between the internal opening of the fistula and the external. It is a loop. It is not a cutting seton – I never put a seton drain in that needs to be tightened. It is basically just a little piece of soft plastic requiring no maintenance on the part of the patient and no home care.

Thanks Rose for posing the Question!

SPANC Minutes

SPANC Meeting Minutes
November 5, 2008

In Attendance
Ramona Hackett
Sandi Weir
Janet Stimec
Jane Atkinson
Rose Diamond
Betty Mannino
Debbi Jugmohan
Delia Muresan
Anna Jackson
Mila Kaplanski
Carol Deriet

Meeting commenced at 11:35

1. It was noted that many months have passed since there has been a formal SPANC meeting. Minutes from Jan 31, Apr 3, and June 4 reviewed and discussed.
2. Meeting times discussed and revised. Decision made to conduct SPANC meetings first Wednesday of every month between 11:30-13:30 in room MB206
3. As SPANC is intended to be inclusive of ALL PeriAnesthesia areas, it has been decided that it is necessary to have a representative, and co-representative for each unit. The representatives will encourage staff to attend SPANC meetings
Janet Stimec has agreed to be the representative for PACU with Sandi Weir being the co-representative.
Debbi Jugmohan has agreed to be the representative for SSSU.
Volunteers are required to be representatives and co-representatives for PAC and SDS

4. Betty Mannino and Sandi Weir have agreed to take turns attending Corporate Nursing council every other month. Jane Atkinson has indicated an interest in rotating through.
5. Ramona would like to see more people contributing towards the Blog. Ideas are needed that will address concerns, promote education and information, quizzes, etc.
6. Handover Tool discussed. It has been noted that SDS has not been completing their section of the tool. It is felt that there is already so much documentation to do and that there is not enough time to fill in one more document when the priority is preparing the patient for the OR. Some of the information in their section is redundant. Discussed that this project was to promote continuity of communication, and to be one of the first PeriAnesthesia areas in the country to trial this. Agreed that as it is a trial, there is room for adding/eliminating sections. In the meantime, SDS encouraged to try to complete their section, or at least the areas pertaining to CPAP and patient Belongings.
7. Carol added that there have been too many cases now where CPAP machines have gone missing and that there needs to be a sign-over sheet from one RN to another, or porter to RN etc.
8. PACU is trialing new lunch hours 11, 12, 13,1400hrs. Evening shift would like to change their break hours as well---is this possible?
9. Discussion of Policies that need to be worked on:
-Visitor policy in PACU
-Medication policy for RN’s working in PAC/Ambulatory assessment
-Pre-op diabetic protocol (what should the RN’s be telling patients who are insulin dependant?)

10. SDS would like to update patient discharge information. Tracey DasGupta (APN from Odette) would also like to be involved with this project. Need to determine Surgeon’s preference as well.
11. Poster presentation at the NAPAN conference regarding Handover Tool.
*possible poster presentation regarding Best Practices in normothermia---something to think about


ACTIONS REQUIRED PRIOR TO DEC 3 MEETING
1. Book MB206 for the first Wednesday of every month 11:30-13:30. DONE
2. SSSU Co-Reprehensive: ___Seema Ratanshi____
PAC Representative: _____________________________________
PAC Co-Representative:__________________________________
SDS Representative: _____________________________________
SDS Co-Representative:___________________________________
3. Sandi Weir to addend Corporate Nursing Council November 26th. Betty to give Sandi the package. -Sandi to arrange schedule with Vicky.
-Jane to arrange schedule if she would like to attend this month.
4. All members to forward ideas for Blog to Ramona
5. All areas to complete their section of the Handover Tool during this trial period
6. CPAP sign-over sheet to be designed and implemented
7. Bring PAC Booklet to Dec 3 meeting to start discussion re: policy development surrounding visitors and medications
8. SDS RN’s to develop list of surgeries requiring discharge information
9. Discuss with SSI group regarding temperature discharge criteria for laparotomy patients
Meeting adjourned at 13:10
Next SPANC meeting Wednesday, December 3, 2008 - MB206 - 1130-1330