Monthly Medication Safety Webinar :

1. Monthly Medication Safety Webinar: All lines will be muted during the presentation and unmuted during questions. If you do not have a question to ask, please mute your phone. If you do not have a mute button on your phone you can press *6 to mute your line. Please do not put the conference on hold. If you would like to ask a question during the webinar please enter the question into the question box.

2. OPIOIDS: Embedding Safety Science in Medication Management System Jocasta N. Gee, Pharm.D. Hospital Corporation of America (HCA) University of Tennessee College of Pharmacy Nashville, Tennessee L. Hayley Burgess, Pharm.D. Hospital Corporation of America (HCA) Nashville, Tennessee Jennifer Higdon, Pharm.D., BCPS HCA-TriStar Division Chattanooga, Tennessee Jason Wright, Pharm.D. TriStar Centennial Medical Center Nashville, Tennessee

3. Joint Commission Sentinel Event Alert

4. Med Man System Topic • Effective processes • Ordering • Procurement • Safe technology • Transcribing • Administration • Storage • Preparing and Dispensing • Appropriate education and training • Patient Monitoring and Metrics • Patient Education • Training • Effective tools • Process Mapping • FMEA • Action Plan

5. Effective Processes

6. Ordering

7. Initial Assessment • Screen patients for respiratory depression risk factors • Assess the patient’s previous history of analgesic use • abuse, duration and possible side effects to identify potential opioid tolerance or intolerance. • Conduct a full body skin assessment of patients prior to administering a new opioid to rule out • an applied fentanyl patch • implanted drug delivery system • infusion pump Jarzyna D, Pain Management Nursing. 2011. Dahan A. Anesthesiology, 2010. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons.Journalof the American Geriatrics Society. 2009.

8. Treatment • Use an individualized, multimodal treatment plan to manage pain. • Psychosocial support • Coordination of care • Nonpharmacologic approaches • Non-opioid pain medications • Treatment Approaches • Avoid rapid dose escalation of opioid analgesia • Take extra precautions when • Transferring patients between care units • Transferring patients between facilities • Discharging patients to their home. • Consider that drug levels may reach peak concentrations during transport. • Avoid using opioids to meet an arbitrary pain rating or a planned discharge date. • Dosing should be based on the individual patient’s need and condition. Jarzyna D, Pain Management Nursing. 2011. Dahan A. Anesthesiology, 2010. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons.Journalof the American Geriatrics Society. 2009.

9. Effectiveness • Assess the pain using a standardized pain scale • Ask the patient • If the patient is unable to communicate, assess pain based on behavioral cues • Frequency of assessment should be: • Initial • Every 8 hours for mild to moderate pain • Every 2 hours for severe pain • Standardized tools can be used to screen patients for undersedation, oversedation and respiratory depression • Pasero Opioid-Induced Sedation Scale (POSS) • Richmond Agitation-Sedation Scale (RASS)

10. Objective Pain Scales

11. Subjective Pain Evaluation • Most common determination of pain in the ICU due to sedation and/or cognitive impairment • Need a patient-specific strategy • Assess patient movement, facial expression, and posturing • Physiologic manifestation of pain: • Tachycardia • HTN • Increased RR • Diaphoresis • Mydriasis

12. Assessment of Pain (FLACC Pain Scale)

13. Assessment of Neuropathic Pain • Neuropathic Pain questionnaire – Short Form • Rate the following aspects of your pain (0‐10 scale): • Tingling pain • Numbness of pain • Increased pain due to touch Backonja M, Krause SJ. Neuropathic Pain Questionnaire – Short Form. Clin J Pain 2003;1995)L315-316.

14. Strategies to Reduce Errors with Ordering Minnesota Hospital Association. The Road Map to a Medication Safety Program. 2012. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

15. Strategies to Reduce Errors with Ordering (cont.) Minnesota Hospital Association. The Road Map to a Medication Safety Program. 2012. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

16. Procurement

17. Strategies to Reduce Errors with Procurement • The facility has a pain management process in place, which includes: • Pain management specialist available for consultation, either onsite or external, which provides mentoring as well as specific consults • High-Alert medication policy and formulary review • Pain medication stewardship program in place • Processes for identification and implementation of best practices • Daily monitoring of adherence to best practices • Plan for intervention of deviation from best practices • Processes for monitoring patient pain management satisfaction scores • Standardized pain assessment scales are used throughout the facility • Process in place to discuss and agree upon specific pain goals and strategies with the patient prior to a surgical procedure Minnesota Hospital Association. The Road Map to a Medication Safety Program. 2012. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

18. Safe Technology

19. Transcribing

20. Equianalgesic Conversion Process McPherson M. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. 2010. McPherson M. 2011 Update to Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. McNicol E. Opioid Analgesics: Administration issues, Side-effect management, and Equianalgesic Conversion. 2008;5(1):16-25.

21. Analgesic Equivalencies McPherson M. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. 2010. McPherson M. 2011 Update to Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. McNicol E. Opioid Analgesics: Administration issues, Side-effect management, and Equianalgesic Conversion. 2008;5(1):16-25.

22. Clinical Pharmacology Opioid Calculator

23. Fentanyl Patches

24. When to use fentanyl patches? • Opioid Tolerance-Adaptation to a drug which results in decreased effects over time • Opioid Tolerance can be defined as taking one of the below for a week or longer • 60mg of oral morphine per day • 30mg of oral oxycodone per day • 8mg of oral hydromorphone per day • OR an equianalgesic dose of another opioid Barr J, Fraser G, Puntillo K, et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. 2013:41(1);263 – 306. Mularski R. Pain Management in the intensive care unit. Crit Care Clin. 2004:20;381 – 401. Opioid Dosing: Focus on Safety. Pharmacist’s Letter. 2010:26;260712.

25. Converting to Transdermal Fentanyl • Determine the 24 hour parenteral morphine equivalent • Dose patch at 50 – 75% of the previous 24 hours opioid use • Prescribe short acting opioids for breakthrough pain (5 – 15%) of 24 hour dose every 3 hours • Patch duration is 72 hours • Increase the patch dose based on the average amount of additional short acting opioid required in the previous 72 hours • Wait at least 48 hours before adjusting the dose • It may take up to 6 days for fentanyl levels to reach equilibrium on a new dose • Wait two 3-day applications before any further increase in dosage is made • For doses greater than 100 mcg/hr multiple patches can be used

26. Converting from Transdermal Fentanyl • Remove fentanyl patch • Approximate transdermal T1/2 of 17 hrs • 50% decrease in plasma levels • Typically Start Long-acting opioid at least 18 hours after removal • Titrate short-acting opioids for breakthrough pain until LAO is initiated • Common to use 2:1 method (i.e. 2 mg PO morphine/day = 1 mcg/hr fentanyl) • Wait 8 – 12 hours before starting 50% of equianalgesic regimen • Wait 24 hours before increasing to 100%

27. Equianalgesic Conversion Process • Equianalgesic data is approximate! • Many different tables available • Mostly based on single-dose, cross-over studies • Mostly studied in cancer patients • Patient specific factors • Age, organ function, genetics, co-morbidities, medications • Use clinical judgment • Start low and go slow! McPherson M. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. 2010. McPherson M. 2011 Update to Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. McNicol E. Opioid Analgesics: Administration issues, Side-effect management, and Equianalgesic Conversion. 2008;5(1):16-25.

28. Strategies to Reduce Errors with Transcribing Minnesota Hospital Association. The Road Map to a Medication Safety Program. 2012. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

29. Administration

30. Pain Guidelines • Titrate the opioid dose at least every 24 hours and as often as every 2 hours when the pain is severe • Increase the dose by 25-50% or by 50-100% with severe pain • Do not use range orders • Manage breakthrough pain with short acting opioids using 1/3 of the single dose amount or 5-15% of the total daily dose • Use around the clock pain medication not PRN for ongoing pain • Use the KISS principle – Keep It Same and Simple(i.e. use the same opioid for short and long term pain control) Barr J, Fraser G, Puntillo K, et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. 2013:41(1);263 – 306. Mularski R. Pain Management in the intensive care unit. Crit Care Clin. 2004:20;381 – 401. Opioid Dosing: Focus on Safety. Pharmacist’s Letter. 2010:26;260712.

31. Administration: Patient Controlled Analgesia 1Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; February 13, 2014. Hicks R, Sikirica V, Nelson W, Schein J, Cousins D. Medication errors involving patient-controlled analgesia. Am J Health-Syst Pharm. 2008; 65:429-40. Cohen MR, Weber RJ, Moss J. Patient-controlled analgesia: Making it safer for patient. Institute for Safe Medication Practices. April 1, 2006.

32. Strategies to Reduce Errors with Administration Minnesota Hospital Association. The Road Map to a Medication Safety Program. 2012. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

33. Storage

34. Storage: Fentanyl Drip & Epidurals

35. Strategies to Reduce Errors with Storage Minnesota Hospital Association. The Road Map to a Medication Safety Program. 2012. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

36. Preparing and Dispensing

37. Strategies to Reduce Errors with Preparing/Dispensing Minnesota Hospital Association. The Road Map to a Medication Safety Program. 2012. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

38. Appropriate Education and Training

39. Patient Monitoring

40. Patient Monitoring: Effectiveness • Opioid analgesics rank among the drugs most frequently associated with adverse drug events. • The literature provides numerous studies of the adverse events associated with opioids. • The incidence of respiratory depression among post-operative patients is reported to average about 0.5 percent. • Some of the causes for adverse events associated with opioid use are: • Lack of knowledge about potency differences among opioids. • Improper prescribing and administration of multiple opioids and modalities of opioid administration (i.e., oral, parenteral and transdermal patches). • Inadequate monitoring of patients on opioids. Swegle J, Logemann C. Management of Common Opioid-Induced Adverse Effecs. American Family Physician 2006:74(8);1347 – 1354. McNicol E. Opioid Analgesics: Administration issues, Side-effect management, and Equianalgesic Conversion. 2008;5(1):16-25

41. Patient Monitoring: Adverse Events • Educate and assess the staff understanding of potential adverse effects of opioid therapy. • Educate and provide written instructions to patients who are on opioids (and to the patient’s family or caregiver). • Common Adverse Events: • Sedation • Nausea/Vomiting • Constipation • Pruritis • Respiratory Depression • Confusion/Mental clouding • Less Common Adverse Events: • Euphoria or dysphoria • Dependence • Withdrawal • Can occur within 12 hours of discontinuation • Sweating, agitation, diarrhea, tachycardia, rebound pain Swegle J, Logemann C. Management of Common Opioid-Induced Adverse Effecs. American Family Physician 2006:74(8);1347 – 1354. Swegle J, Logemann C. Management of Common Opioid-Induced Adverse Effecs. American Family Physician 2006:74(8);1347 – 1354. McNicol E. Opioid Analgesics: Administration issues, Side-effect management, and Equianalgesic Conversion. 2008;5(1):16-25

42. Monitoring Makes a Difference • Study Design • The Committee for Safe Medication Practice at Wesley Medical Center in Wichita, KS, has improved patient-controlled analgesia (PCA) outcomes by developing and implementing: • A sleep apnea risk assessment model • Evaluates all adult patients • Uses modified STOP-Bang scoring system • Risk documented in electronic health record • Dosing parameters • Robust monitoring • The consistent use of capnography to monitor respiratory status. • Results • Decreasing the percentage of moderate and severe patient-controlled analgesia adverse events progressing to code blue from 13 percent to zero percent.

43. Strategies to Reduce Errors with Monitoring Minnesota Hospital Association. The Road Map to a Medication Safety Program. 2012. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

44. training

45. Training • Assess your organization’s need for training based on: • Analysis of reported adverse events • Near misses • Staff observations • Training Examples • Initial training for new hires and existing staff, including protocols, guidelines, onboarding materials • Post-test incorporating a case-­study approach to demonstrate proficiency covers topics such as dose stacking, dose equivalency, interpretation of vital signs and monitoring equipment • Identify knowledge gaps and develop improvement strategies to reduce recurrences • Ongoing opioid education is provided when new relevant information is available

46. Effective Tools

47. Process mapping

48. Opioid Use Process

49. fmea

50. Top 8 Failure Modes Identified