Pharmacy & Therapeutics- July 2008 - (Page 424) Pain Management and Medication Errors be one route an organization may take toward reducing risk for opioid-related ADEs. Second, standard monitoring is insufficient for the reliable detection of respiratory depression from opioids. Oximetry alone is limited in its ability to establish the presence of hypoventilation. Although supplemental oxygen is quite sensitive for detecting hypoventilation in patients who are breathing room air,25,26 its use, which is nearly uniform in high-risk patients, can impair the ability to detect apnea via continuous pulse oximetry monitoring.27 Third, the potency of hydromorphone is generally underappreciated and is relatively new to many physicians. Since our hospital’s renewed interest in this agent, we learned of an internist who prescribed intravenous (IV) hydromorphone 4 mg for an opioid-naive patient who had complained of a migraine. Fortunately, an astute nurse questioned the order, and the pharmacist discussed the problem with the physician, who had thought that hydromorphone was relatively equivalent to morphine on a milligram-for-milligram basis. On the contrary, hydromorphone is roughly eight to 10 times more potent than morphine. Even with appropriate awareness of dosing equivalency, however, problems can still occur. Patanwala warned that opioid conversion tables do not always accurately reflect dose ratios that are firmly evidence-based, particularly when these medications are used in the acute-care setting.28 Fourth, patients can develop respiratory depression and respiratory compromise relatively quickly, often without first manifesting signs of difficulty related to opioids. In a study of opioid ADEs in an inpatient setting, Vila et al. found that in 29 events resulting in the need for naloxone, intubation, or both, the respiratory rate averaged 18 breaths/minute just before the event.18 In fact, in only three of the 29 cases was the respiratory rate noted to be low.18 Relying on the respiratory rate and pulse oximetry alone, particularly in patients receiving supplemental oxygen, is fraught with hazards, because the enhanced oxygen concentration can mask desaturations that might signal hypoventilation; in addition, measurements of respiratory rate often do not take into account the adequacy of the ventilations. Fifth, clinical staff personnel should be aware that the numerical pain ratings are only one dimension of the patient’s subjective experience of pain. Full assessments must consider the multiple components of the experience of pain, including the physiological,29 behavioral,30 sociocultural,31 and cognitive32 components. with sedative properties are prescribed. 5. Institutions should actively involve pharmacists in painmanagement programs. Our experience argues for adding the following recommendations to the list: 1. All staff members should be instructed about the dosing equivalency of the various opiates on formularies. 2. The goal of pain management should be redefined. The goal is not a subjective pain score of zero; rather, it is the best possible subjective experience of pain that can be safely achieved with a multimodality approach. 3. Pain orders should be standardized. Figure 1 presents an example of the pain-management order set we developed in response to recent events at our hospital. 4. It might be prudent to acquire capnography for monitoring, particularly for high-risk patients (e.g., those with a history of sleep apnea, upper-airway disorders, or extremes of age and weight). Capnography can be more sensitive than closely monitored routine anesthesia care in detecting hypoventilation.33 Our hospital has purchased new monitors with noninvasive capnographic capability for high-risk areas, as recommended by our Departments of Anesthesia and Critical Care. Conclusion The Joint Commission has the right idea. Patients have the right to optimal pain relief, and we need to continue to work toward that end—but without sacrificing safety. Organizations should assess their practice of pain assessment and pharmacological pain control with the goals of (1) ensuring that all clinicians are appropriately educated about the need to assess pain on a multifactorial basis and not to simple rely on the patient’s subjective rating, and (2) standardizing health care delivery in order to reduce unnecessary variance that can contribute to error and risk. References 1. McCaffery M, Pasero CL. Pain ratings: The fifth vital sign. Am J Nurs 1997;97:15–16. 2. Kozol RA, Voytovich A. Misinterpretation of the fifth vital sign. Arch Surg 2007;142:417–419. 3. Pell G. Use and abuse of Likert scales. Med Educ 2005;39:970–971. 4. Jamieson S. Likert scales: How to (ab)use them. Med Educ 2004; 38:1217–1218. 5. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973;78(2):173–181. 6. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 1995;274(23):1874–1880. 7. Lanser P, Gesell S. Pain management: The fifth vital sign. Healthcare Benchmarks 2001;8(6):62, 68–70. 8. Bergman v Eden Medical Center, Case No. H205732-1. Superior Court of California, Almeda County, 2001. 9. Zacny J, Bigelow G, Compton P, et al. College on problems of drug dependence task force on prescription opioid non-medical use and abuse: Position statement. Drug Alcohol Depend 2003;69(3): 215–232. 10. Automation of Reports and Consolidated Orders System (ARCOS). U.S. Department of Justice. Available at: www.deadiversion. usdoj.gov/arcos. Accessed January 22, 2008. 11. Gutstein HB, Akil H. Opioid analgesics. In: Hardman JG, Limbird LE, eds. Goodman and Gilman’s Pharmacological Basis of Therapeutics, 10th ed. New York: McGraw-Hill; 2001:569–620. Recommendations for Managing Pain Safely Having recognized the growing risk of ADEs related to the pain-management process, the ISMP issued the following recommendations:19 1. It should be determined how well organizations are managing pain. 2. Staff personnel should seek to uncover episodes of oversedation by monitoring ADE reports, investigating all uses of reversal agents, and conducting chart reviews. 3. The number of various types of analgesics prescribed should be reduced. 4. Caution must be used when combinations of medications 424 P&T® • July 2008 • Vol. 33 No. 7 http://www.deadiversion.usdoj.gov/arcos http://www.deadiversion.usdoj.gov/arcos
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