Safe Use of Opioids in Hospitals:Successful Pain Management and ...

Medication Safety Initiatives:
Risk Reduction Strategies for Safe Opioid Use
June 11, 2013
Presented by:
Miriam Klein, BS, PharmD,
Assistant Director of Pharmacy,
Medication Safety
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Kings County Hospital Center
• Kings County Hospital Center (KCHC) is a 700-bed, level one trauma center, an acute
care academic and public hospital in Brooklyn, New York
• More than 200 clinics provide a wide array of ambulatory care services
• One of 11 hospitals under New York City Health and Hospital Corporations (NYC HHC)
• Mission to provide care to everyone regardless of their ability to pay
• Electronic Health Record (eHR)
• Computer Physician Order Entry (CPOE) implemented
• System includes decision support and standardized order sets
• Guide use of formulary drugs and protocols
• Electronic Medication Administration (eMAR)
• Bar Coded Medication Administration (BCMA)
• 90% BCMA Compliance
• Accredited in June 2012 by The Joint Commission
• Cited by surveyors for numerous “Best Practices” including High-Alert Medication Program

Turning a Personal Tragedy Into a
Passion for Avoiding Medication Errors
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Turning a Personal Tragedy into a
Passion for Avoiding Medication Errors
“Life-long disability impetus fuels my passions for helping
others to avoid such errors”
Currently, Assistant Director of Pharmacy, Medication Safety at
Kings County Hospital Center
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“Deep Dive” Medication Chart Review
Adverse Drug Reactions Data
Analysis (Jan-Dec 2011)
• Reported by various ways:
–Adverse Drug Reaction (ADR) Hot-line
–Behavioral Health Service via email
–Fall Committee Monthly Reports of Patients Falls
–Recent: December 2011 Code 99 Patients List
•Review any earlier adverse drug reactions prior to
date/time of fall
• Assistant Director of Pharmacy,
Medication Safety:
–Review each reported adverse drug reaction
–Fall Committee Monthly Reports- Review each
patient’s medication profile before and after
documented date/time of fall
• Generate analysis of medications
that may cause ADRs
• Drill down to the significant timing
and doses:
–Are the medications classified as high alert
medications?
–Was it a medication error?
Medication Errors Data Analysis
• Evaluate medication errors –
Jan-Dec 2011 data entries
• Reporting Process:
– Prescribing, Dispensing,
Administration, Documentation,
Computer
• Medication Safety
– Tracking and trending
• Drill down to the significant
problems in medication errors
• Identify the most common issues
– Determine what is the internal data
telling us?
– Risk reduction strategies to reduce
the identified problems in
medication-use process
Updates: Congestive Heart Failure (CHF) Readmission Task Force and Medication Reconciliation

Safe Opioid Use:
Proactive Risk Assessment
• Used data analysis from internal KCHC
Adverse Drug Reactions Reports
• Identified area for concern: “trigger drug”
naloxone as reversal agent
• Discovery : HYDROmorphone (High-Alert)
High-Alert Medications as defined by The Institute for Safe Medication Practices (ISMP):
”High-alert medications are drugs that bear a heightened risk of causing significant patient harm
when used in error. Although mistakes may or may not be more common with these drugs, the
consequences of an error are clearly more devastating to patients” 1
– Challenges:
• Injectable route prescribed overwhelming majority of time
• High dosages frequently prescribed
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Medication Safety Issues:
HYDROmorphone
Multidisciplinary teamwork - 2012
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HYDROmorphone:
A High Alert Drug
• Assemble a multi-disciplinary team in March 2012
• Share and learn meetings as medication safety initiative
• Focus on patterns of HYDROmorphone usage
• Understand potency of HYDROmorphone
– 1mg IV HYDROmorphone = 7mg IV morphine
• Review to remove route “IM” (intramuscular)
• Review practices for assessment
– Guidelines for monitoring and documentation (vital signs & sedation
scale)
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HYDROmorphone Issues:
Raising Awareness
• KCHC Internal Database Findings 2011
– Adverse Drug Reactions
• Naloxone administration as rescue drug
– Medication Errors
• Significant Risk of Harm
• Global under-appreciation of potency
– Lead to higher doses prescribed
• Significant risk of serious adverse drug events
– Respiratory Depression
– Sedation/Drowsiness – contributes to falls
• Opioid Tolerant versus Opioid Naive
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Data Analysis KCHC HYDROmorphone

Findings-Clinical Assessments

Risk Reduction Strategies

HYDROmorphone: KCHC Analysis
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Educational Implementations
• Screen Saver on KCHC desktop
• KCHC Opioid Handbook for Clinicians
– Printed and on-line versions
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Risk Reduction Strategies: PCA
• CPOE Pre-Built Order for PCA Morphine
• Drug Library for PCA Pump
• Educational Alert
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Pre-Built CPOE
• Common Order Options
• Analgesics
• ICU Sedation and Analgesics Medication
Orders
• Proced. Sed. Analgesia (PSA)
• PRN Pain In-Pt Orders
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Special Thanks
• Christopher Russo, Director of Pharmacy
• Jalil Minhas, Assistant Director of Pharmacy, Informatics
• Chief of Pain Management
• KCHC Multi-Disciplinary Team:Prescribers, Nurses & Pharmacists
• KCHC Leadership and IT
• NYC HHC Medication Safety Council
• GNYHA Clinical Pharmacy Team-HYDROmorphone Research Articles
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THE END
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