Painkiller Precautions
When patients leave the hospital, there is far less ability to monitor patients’ use of and response to these medications. Sending patients home from the hospital with unnecessary opiate prescriptions can create potentially serious problems for patients and/or those around them. The more an addictive drug is prescribed, the more likely it will be diverted and abused.60
Especially upon discharge, it is critical that patients and their lay caregivers understand the importance of using the least amount of opiate medication required, as well as the signs of opiate overdose and dependence, the dangers of mixing opiates with alcohol and other medications, and the fact that a personal and family history of alcohol and drug abuse may increase a person’s chance of opiate abuse or diversion of their medications for misuse by themselves or others who have access to them. Simply asking patients if they have a history of alcohol or substance abuse is not a sufficient preventive measure. Without adequate knowledge about why this question is asked, many patients fail to appreciate the importance of full disclosure.
A Nurse’s Nightmare, Anyone’s Nightmare
Worldwide, up to thirty-six million people abuse prescription opiates, including about 1.5 million Americans over the age of twelve.61 The problem has hit healthcare providers hard, especially nurses. The Nurses is an in-depth investigation of the working lives of hospital nurses and their shocking behind-the-scenes secrets by best-selling author Alexandra Robbins. The book follows a nurse who struggles with her addiction to opiates and history of taking doses prescribed for her patients. The author describes the tactics that nurses use to steal these medications from hospitals, nursing homes, hospice care centers, and other workplaces.62 For example, nurses are supposed to “waste” (safely discard) patients’ leftover pain medications, but it is easy for them to take them home. One nurse admitted to peeling pain patches off nursing home patients.63 It is also easy for nurses to give patients only a portion of what is prescribed for them and pocket or shoot up the rest. Furthermore, a number of studies suggest that the problem is actually many times higher among nurses than the general population due to their chronic work-related stress and easy access to these powerful drugs. Robbins notes that the American Nurses Association estimates that 6 percent to 8 percent of nurses are now impaired at work due to substance abuse, often involving opiates.
The Nurses also includes this riveting side note: Jan Stewart, a twenty-eight-year certified nurse anesthetist who was president of the American Association of Nurse Anesthetists and widely respected and beloved by colleagues, suffered from addiction to opiates and died at the age of fifty from an opiate overdose. Nurse Stewart’s addiction began with the painkillers she was prescribed after back surgery. Just as a main character in The Goldfinch,64 a 2013 Pulitzer Prize–winning novel, nurses (and others) can appear to be functioning relatively normally while seriously abusing opiate drugs. Such may be true of other groups of employees, especially those whose jobs place them at high risk of being physically hurt or injured.
According to anonymous surveys colleagues and I collected in October 2016 from industrial workers from over fifty companies in Virginia, over 10 percent reported they sometimes take prescription pain medication to perform their jobs. While some percentage of the respondents may have been referring to the use of non-narcotic prescription pain medications, this is unlikely to be the case for the majority of them. A recent twenty-one-state analysis of treatment for work-related injuries that did not require surgery indicated that 78 percent of employees received opioids, with state rates ranging from a low of 60 percent (Connecticut) to a high of 90 percent (Arkansas). Although respondents to our Safety & Leadership Survey were not from one of the highest opioid use states, they were from the southeastern region of Virginia known as Hampton Roads, which has a documented problem with the overuse of opioids.65 Moreover, the rate of opioid use among injured workers is high (60 percent or greater) even in states with comparatively low rates of opioid use.
The problem of opiate-heroin abuse can strike anyone, anywhere. Carolyn Weems was right to be worried about others suffering the same tragedy that her family must now endure. Between 1995 and 2002, the number of American teenagers who had used heroin increased 300 percent. So in 2015, Weems posted about the problem on the Virginia Beach City Public Schools website, wrote about it in the local newspaper, and convened a meeting of over two hundred parents and professionals from Virginia Beach to candidly discuss the issue.
In her crusade, Weems grabbed the attention of Virginia’s attorney general, Mark Herring. Ever since, Weems and Herring have been dedicated to making the public aware that people of all ages, stages, and classes are using heroin. In 2014, more teens in Virginia died from heroin than from car accidents.66 A 2015 investigation revealed that nine hundred nurses in Virginia were publicly disciplined for stealing drugs at work in the past few years.67 The problem of opiate/heroin addiction is not limited to Virginia; it is a serious national epidemic. In fact, looking at the rate of opiate prescriptions by state, Virginia falls in the bottom half.68
We can, and must, do a better job of managing patient pain while averting such unacceptably high rates of opiate prescriptions, diversion, abuse, addiction, and death. Indeed, providers must familiarize themselves with the CDC opiate guidelines that were released in 2016 that promote judicious use of opioid painkillers;69 however, solving the opioid/heroin epidemic will require a societal—not just medical—response. Moving forward, efforts to curb this epidemic will require dedication inside hospitals as well as in our communities.
In addition to providing a summary of key information (table 5.3), a patient action plan (table 5.4), and a sticky message with sample language for promoting safe medication administration (table 5.5), this chapter also offers a summary of key information about the safe management of opiate drugs (table 5.6).
Table 5.3.
What You Need to Know
Medication Administration Errors
Information for Patients
Medication errors are common. Every patient is at high risk. On average, hospital patients experience one medical error per day. Such errors are even more common in nursing homes. Most hospitals use electronic health records and other technologies to reduce the chance of drug errors, but technology cannot catch all errors. Making sure you receive the correct drugs (and only those drugs) requires focused attention.
Whenever you are able to participate, nurses should invite you to verify your identity and review these Five Rights:
1
Right Patient
2
Right Drug
3
Right Dose
4
Right Route
5
Right Time
Information for Providers
Approximately 17 million drug errors occur in US hospitals each year. The rate of error is even higher in US nursing homes. Hospitals use various technologies to prevent drug errors, but technology is not perfect. It is only as good as the systems that support it and the people who use it. So, never allow yourself to develop a false sense of security because technology usually gets things right.
While there is no magic bullet for preventing all medication errors, two safety habits can eliminate many of them. Whenever possible involve patients to: (1) verify their identity and (2) review the Five Rights of Medication Administration. Doing so creates a two-person check without needing to track down another prov
ider, and it has the potential to catch up to 95 percent of medication administration errors.
Table 5.4.
Patient Action Plan
Medication Administration Errors
TIMING
PATIENT ACTION
✓
ASAP
I created a written list of all my medications, including:
prescription drug dosages, routes of delivery (oral, patch, etc.), and timing (how often I take it)
over-the-counter drugs I take on a regular basis
my name and date of birth
I am prepared to bring my medication list to all medical appointments and facilities where I will be treated.
I reviewed my medication list with a family member or friend and/or let someone know where I keep it, so they can help in an emergency.
Before being admitted to a hospital
I know the Five Rights refer to the right:
(1) patient, (2) drug, (3) dosage, (4) route, and (5) time.
I practiced what to say if a nurse or someone else attempts to give me a drug without reviewing the Five Rights with me.
I will expect my identity to be verified by two pieces of information before a drug is given—even if this must happen many times each day.
I will speak up whenever care providers: fail to introduce themselves, verify my ID, review the Five Rights with me; or if something doesn’t seem right.
Table 5.5.
What You Can Say
Sticky Message:
Safety Starts with a Name
When Someone Walks into a Patient Room without Introducing Himself or Herself
Patient Request—Examples
Desired Response—Examples
“I’m glad you’re here to help, but would you mind introducing yourself?”
“Forgive me for not introducing myself. My name is ___. I am a ___. I am here to ___.”
“I know you’re my nurse, but I’ve forgotten your name and I’m wondering what you’re doing to my IV bag.”
“My name is Laura. I will be your nurse until 10 p.m. and I am here to check your medications at the start of my shift. Sorry I didn’t explain that when I walked in. How are you doing?”
Sticky Message:
ID Me Before You Treat Me
When Someone Wants to Do Something to You without Verifying Your ID
Patient Request—Examples
Desired Response—Examples
“Nurse Mary, I know we’re familiar with each other, but let’s double-check my ID and review the order before you push drugs through my IV.”
“Thank you, Mrs. Jones. This is a busy place. I don’t want to let a mistake slip through the cracks.”
“Mr. Brown, I’m eager to get my X-ray, but would you verify the name on the order before you transport me?”
“Absolutely! Thanks for checking. I meant to do that. Let’s do that right now.”
Sticky Message:
No Review, No Drugs
If Someone Attempts to Administer a Medication Before Reviewing It with You
Patient Request—Examples
Desired Response—Examples
“It might have been reviewed before, but let’s make sure we have the right patient and medication.”
“Thank you for checking. Let’s check that your wristband matches the order and review the order together. Let me know if anything is incorrect, if you have questions or something doesn’t seem right about the drug, dose, method of delivery, or timing.”
“Nurse Kevin, before you connect that medication bag, would you mind reviewing the order with me?”
“Of course! I love caring for patients who help make sure we get things right.”
“Dr. Jones, as far as I know, there have been no changes to my medication, but let’s review everything to make sure no mix-ups have occurred.”
“Yes, let’s do that right now. I am glad you’re paying close attention to the medications you are getting.”
Table 5.6.
What You Need to Know
Opioid Painkillers
Information for Patients
Opioid painkillers are one of the most commonly prescribed medications. They are important for helping patients manage their pain, especially after surgeries and invasive procedures. Opiates can speed the recovery process by helping patients resume normal activities as soon as possible. However, these drugs are powerful, addictive, and overprescribed.
The need for painkillers is subjective, and the ability of patients to tolerate such drugs varies widely. Disclose any history of alcohol or drug abuse to your providers because this can affect your reaction to the medication. Always take as little pain medication as necessary. Although hospital providers do everything they can to monitor patient reactions to pain medications, patients are unique and patient status can change rapidly. Therefore, family and friends involved with your care must feel free to call attention to any signs that you may be overly sedated or dehydrated.
Even highly competent doctors and nurses can overlook important signs and symptoms. To the best of your ability, speak up if you feel unnecessarily sleepy, unresponsiveness, or dehydrated. Ask about nondrug treatments for pain and non-narcotic (nonopioid) pain medications. They can be as (or more) effective than opioids for treating chronic pain.
Information for Providers
Beginning in the 1990s, pharmaceutical companies and pain management experts promoted opioid painkillers as relatively nonaddictive, but we now recognize that opioid painkillers are highly addictive. They should be used sparingly and not as a first-line treatment for chronic pain.
Because opioid use has increased dramatically over the last five to ten years, opioid addiction now affects 2.5 million Americans on a daily basis. Once addicted, many people turn to inexpensive heroin when they cannot afford to obtain prescription opioids. In fact, 80 percent of heroin users first used opioids for pain relief.
In 2016, the CDC released a new opioid guideline. Familiarize yourself with its twelve specific recommendations to help you determine (a) when to initiate or continue opioids; (b) how to select, dosage, monitor, and discontinue opioids; and (c) how to assess opioid risks and harms.
Chapter 6
Beyond the Bedside
Improve Patient Safety One Community at a Time
A Deadly Chemotherapy Mix-Up
The mother said, “That doesn’t look like the chemo she has gotten previously. Are you sure it’s right?” She asked again a bit later. And she asked a third time. She was right and her child—who had a curable cancer—died of a chemotherapy mixture error. The nurse confirmed each time that the label on the bag was accurate. And each time, the nu
rse assured the mother it was the right medication. And she was right—the label said the right thing. But that wasn’t what was in the bag.
I was responsible for the pharmacy and pharmacists who were the source of the error and resulting death of a lovely seven-year-old girl and the devastation of a mother who felt she didn’t do enough to protect her child. As an organization, we were long in our safety journey and this horrific death showed us how far we had to go. Together with the pharmacy department team members, we faced the reality of what we had done and created a short list of terrible things never to be repeated.
—Roundtable participant, NPSF Lucien Leape Institute1
United in Safety
Every time I read the above excerpt, I cringe. This tragic chemotherapy mix-up exemplifies how easy it is for mistakes to occur and reminds us that patient concerns are too likely to be overlooked, even when they signal that a major patient safety event may be about to occur. Like the examples in previous chapters, this story exposes how devastating it can be for patients when basic human error slips through the cracks. It also reminds us that providers don’t walk away unscathed.
With a vision to create a world where both “patients and those who care for them are free from harm,” the National Patient Safety Foundation recently updated its strategic plan with four major goals. It now seeks to:
Your Patient Safety Survival Guide Page 14