Narcotics and sedatives provide patients with relief from pain and discomfort. However, doses must be selected carefully and patients monitored closely to prevent accidental overdoses and adverse drug events (ADEs). Using standardized approaches, such as pre-printed orders and protocols and verification of equipment settings, helps reduce the risk of errors that can lead to ADEs. Remember that inadequate dosing of these medications can also lead to ADEs, such as uncontrolled pain and the subsequent effects. Strategies such as using pain management teams can help clinicians manage pain and sedation effectively yet safely.
Changes for Improvement
Implement a Pain Management Team
A pain management team can be a great resource to clinicians managing patients in pain. If a patient’s pain is not being relieved adequately or is difficult to control, consultation with a team of experts can often help the situation. Train a team of internal staff in pain management assessment and treatment technique, and then establish a program so that the team can be called for assistance.
- Set criteria for automatic consultation with the team, such as when a patient’s pain level exceeds a certain level over a specified period of time.
- Work with physicians to determine the role of the team, that is, to specify whether team members can order or adjust pain regimens.
Consider Non-Pharmacological Interventions for Pain and Anxiety
Pain and anxiety experienced by patients can sometimes be reduced with non-pharmacological interventions, such as deep breathing and relaxation techniques. These interventions do not have the risk for adverse events that narcotics and sedatives do. When a patient is in pain or is anxious, try using a non-pharmacological intervention first.
- Use non-pharmacological interventions only when it is appropriate to try them. For example, it may not be appropriate with patients who have just had surgical procedures.
- Train staff in use of relaxation techniques and other non-pharmacological interventions, so that they can help patients properly use them.
Use Programmable Pumps and Independent Double-Checks with IV and Epidural Narcotics and Sedatives
Programmable pumps provide safety features that control the amount of solution delivered per hour to a patient. These safety features are not available with hanging intravenous solution bags alone. By controlling the amount of solution delivered, programmable pumps thus help prevent inadvertent overdosing or under dosing, which can lead to dangerous adverse drug events. Two clinical staff members should perform independent double-checks to make sure the pump settings are correct and consistent with current orders.
- Perform independent double-checks when administration of the drug starts, each time the dose is changed, and at the change of each shift.
- Include patient-controlled analgesia (PCA) pumps in the double-checks, too.
- Use pumps that prevent a free-flow administration of solution.
Use Only One Model of Pump for Administering Narcotics and Sedatives
Different manufacturers’ pumps for administration of medications in solution, and even different model pumps from the same manufacturer are set up very differently. They may look different, have different features, or have the same features but located in different places or set differently. Visual displays and alarm features usually vary as well. Having more than one model of pump in use in a health care organization increases the chances that staff will confuse the pumps and make an error in setting the flow rate for administration of a drug in solution or troubleshooting the pump when there is a problem. Since flow rate affects dosage received by the patient, setting the wrong flow rate can result in an overdose or under dose, which can lead to a severe adverse drug event. To reduce the risk of such error, select only one model and standardize it across the organization. That way, staff can become familiar with all of the features and settings of the pump and avoid errors.
- Involve staff in the selection of the pump to be used, since they are the ones who will have to work with it every day.
- Look for pumps that have safety features and take human factors into account during design.
Use Protocols or Order Sets for Prescribing Narcotics and Sedatives
Unintentional overdose of a narcotic or sedative medication can quickly lead to a serious adverse drug event. Protocols that incorporate pain and sedation scales and order sets in computerized systems (or pre-printed in paper systems) can serve as a guide to help clinical personnel quickly and accurately select the appropriate dosage and adjust it as needed. Prescribers can quickly select the appropriate dosages and pain assessment scales provide information from the patient about whether pain relief has been achieved with the narcotic. Sedation scales provide clinical staff with objective criteria to assess whether the level of sedation is appropriate. Nurses and pharmacists can initiate and manage these protocols, thus saving time both for them and for physicians. It also helps provide more timely adjustments to dosages, which decreases the risk of adverse drug events to patients.
- Work with physicians to develop standardized protocols and order sets limited to as few as possible to decrease the risk of error that comes with multiple versions.
- Set dose limits to avoid inadvertent overdoses.
- Include information about signs and symptoms of overdoses to aid staff in recognizing them.
- Include information about interventions that should be taken if an overdose is suspected, and allow staff to initiate them via the protocol.
Eliminate Use of Meperidine
Meperidine, usually prescribed for pain relief, is known to have some undesirable side effects that may lead to adverse drug events (ADEs). Use other narcotic medications that provide adequate pain relief without these risks. Many organizations have eliminated the use of meperidine entirely, so consider doing the same in your organization.
- Remove meperidine from protocols, orders sets and pre-printed orders as a first step, if there is reluctance to eliminate it entirely. When it is not there as a choice, many prescribers will not even miss it, and usage will drop.
- Review data on usage of meperidine, especially after removing meperidine as a choice. If usage is low, physicians may be more likely to support its removal from the hospital formulary.