CONSULTING ACADEMY REPORT
Got Naloxone?
A
colleague sent me an article addressing negligence and malpractice that resulted in a fatal opioid medication administration error. The subject piqued my interest because I had recently discussed with this same colleague my observation of larger and more frequent dosing of high potency opioids in some of the nursing homes we service. In this particular article, an evening shift nurse mistakenly administered 120mg of Morphine to one resident that was actually prescribed for another. Denise Robertson, P.D. Consulting Academy President
it is administered. Administration of any medication to the wrong resident can have dire consequences. The same can happen with administration of prescribed medication to the right resident if proper attention is not paid. Whenever I have the opportunity for a teaching moment during medication pass, I draw attention to liquid opioid product concentrations, whether a solid dosage form is long acting or short acting, and what kind of measuring device is used to measure liquids. Morphine oral solution is available in 10 mg per 5 mL, 20 mg per 5 mL, and 100 mg per 5 mL (20 mg/ mL) concentrations. When I see the 100 mg per 5 mL (20 mg/mL) concentration prescribed, I take particular care to draw attention to avoid dosing errors due to confusion between different concentrations and between milligrams and milliliters, which could result in accidental overdose and death. The same holds true for oxycodone concentrated oral solution that is available as a 20 mg/mL concentration.
Opioid administration errors are preventable events. As pharmacists, we are well positioned to teach safe practices in prescribing, use and monitoring of all medication.
Realizing her mistake, the nurse followed proper protocol and the physician was notified. The physician ordered naloxone administration with instruction that if the resident did not respond to the naloxone administration, they were to transport the resident to the hospital. The resident became alert and verbally responsive, therefore the nursing home staff decided against sending the resident to the hospital and opted to monitor vital signs. The next morning, the resident was found unresponsive, transported to the hospital and passed away three days later. The cause of death was morphine intoxication. In this case, one dose of naloxone was not enough to save this resident. Proper education of nursing staff in the use of naloxone may have saved this resident’s life. With hospital stays becoming shorter, more residents are being discharged on high potency opioids for acute pain control. We consultants must be sure that naloxone is stocked in the emergency kit. We also need to educate our providers on proper use and follow-up of naloxone. Having naloxone as a safeguard in the emergency kit is comforting, but as we learn from the article, if not used properly, the outcome can be devastating. It is just as important to provide periodic education updates on opioid products, concomitant use with benzodiazepines and how potential administration errors can be made. I always teach the five RIGHTS of medication administration: Right resident, Right drug, Right dose, Right route and Right time. Most medication errors can be avoided by reading the prescription label of each medication every time
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Concomitant use of opioids and benzodiazepines or other CNS depressants may result in profound sedation, respiratory depression, coma, and death. We know that avoidance is best practice but is not always possible. Always stress extra monitoring and vigilance when taken together. Don’t forget another teaching moment concerning fentanyl patches and fever. There is Increased delivery of medication from patches associated with increased temperature. This could be clinically significant for new users of the patch and requires extra monitoring for signs of opioid toxicity. Opioid administration errors are preventable events. As pharmacists, we are well positioned to teach safe practices in prescribing, use and monitoring of all medication. A little extra time spent with the nursing facility team will help to ensure safer resident outcomes. §
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