Patient Safety Checklist Helps Address Opioid Warnings from TJC

Physician-Patient Alliance for Health & Safety checklist supports Sentinel Event Alert on opioid hazards.

On August 8, The Joint Commission issued a Sentinel Event Alert on the safe use of opioids in hospitals. The Alert discussed the significance of accurate pain assessment and effective pain management plans. Tips offered by The Joint Commission included:

  • Screen patients for respiratory depression risk factors.
  • Assess any history of analgesic use or abuse, duration, and possible side effects to identify potential opioid tolerance or intolerance.
  • Individualize the treatment and adopt a multimodal approach. Such an approach combines strategies including psychosocial support, the coordination of care, and the promotion of healthy behavior, among others.
  • Not all pain will go away. Focus on managing pain rather than eliminating it.

The Physician-Patient Alliance for Health & Safety (PPAHS) is an advocacy group dedicated to improving patient health and safety. Doing so involves many facets. Hospitals need to leverage technology to provide necessary monitoring of patient vital signs. Management needs to enable healthcare providers to reduce safety risks by implementing procedures centered on patient safety. Physicians and patients alike need access to information on patient safety and must take an active role in preventing adverse events.

The PPAHS recently released a safety checklist that supports hospitals, management, physicians, and patients in their mission to improve patient safety. The checklist is specifically designed for patient-controlled analgesia (PCA) pumps. Focusing on essential steps that increase patient safety for individuals using PCA pumps, the PCA Safety Checklist will help hospital staff achieve better clinical patient safety outcomes. The PCA Safety Checklist can be viewed and downloaded for free by clicking here.

Below we present four takeaways from The Joint Commission’s Sentinel Event Alert. Following these takeaways will likewise lead to better clinical outcomes that involve the use of opioids for pain management.

1. Implement effective processes when dealing with opioids.
Ongoing clinical monitoring requires policies and procedures that assess the adequacy of respiration and the depth of sedation. In addition to monitoring respiration adequacy and sedation depth, be sure to observe oxygenation and ventilation by using pulse oximetry and capnography. As The Joint Commission Alert advises, it is important to educate staff not to rely on pulse oximetry alone because it can suggest adequate oxygen saturation in patients who are actively experiencing respiratory depression. Pulse oximetry does not detect changes in respiratory rate, depth of breathing, or pauses in breathing. As the Sentinel Event Alert points out, using capnography to monitor ventilation is a valuable addition to pulse oximetry, especially when supplemental oxygen is being used.

Policies and procedures should allow for a second-level review by a pain management specialist. A good policies portfolio will also include procedures for tracking and analyzing opioid-related incidents for quality improvement purposes.

Frank Federico, RPh (Patient Safety Advisory Group at The Joint Commission and executive director at the Institute for Healthcare Improvement) commented on the Alert, saying, “Even with well-developed procedures in place, adverse events with PCA pumps can occur even without a healthcare professional ever committing an error. Moreover, pulse oximetry and capnography are essential risk prevention tools in any pain management plan.”

2. Leverage safe technology when managing pain with opioids.
The Sentinel Event Alert observes that separating sound-alike and look-alike opioids reduces the risk of human error. Further, by building red flags into e-prescribing systems, medical staff can ensure patient adherence to dosing limits. These measures, coupled with the PCA checklist discussed above, can help staff properly oversee of the use of patient-controlled analgesia (PCA) pumps and reduce the risk of over-sedation.

According to Frank Overdyk, MD (executive director for research, North American Partners in Anesthesiology, and professor of anesthesiology at Hofstra University School of Medicine), “PCA pumps provide optimum patient controlled analgesia and high patient satisfaction, yet despite their built-in safety mechanisms, can result in dangerous levels of over-sedation and respiratory depression. These pumps are safest in tandem with continuous electronic monitoring, a combination of pulse oximetry and/or capnography. We need to avoid unrecognized, critical respiratory depression, which can cause tragedies like that of Amanda Abbiehl.”

Amanda Abbiehl was an 18-year old, who tragically died in a PCA-related incident. For more on her story, please visit

3. Introduce appropriate education and training on opioid use.
Advise clinicians who prescribe pain medication on the risks of PCA pumps and provide them with a diverse pain management toolset. Such a toolset, says the Alert, includes physical therapy, acupuncture, manipulation or massage, ice, music therapy, and non-narcotic analgesics.

“Even with alternative treatment plans,” cautioned Dr. Overdyk, “you need to consider all of the risks associated with these alternatives and select the best solution for the individual patient. Educate staff on the tell-tale signs and symptoms of opioid over-sedation and respiratory depression and the importance of frequent patient assessments. Show them how to develop a risk management plan for patients. In addition, teach patients about the risks and side effects of opioids and the importance of safe and secure storage of opioid analgesics at home.”

4. Use standardized tools to reduce opioid risk factors.
Standardized tools such as the Pasero Opioid-Induced Sedation Scale and the Richmond Agitation-Sedation Scale can help screen patients for risk factors associated with over sedation and respiratory depression.

“The Joint Commission recognizes there is an opportunity to improve care for patients by improving the safety of opioid use in acute care settings given that data show opioids are among the top three drugs in which medication-related adverse events are reported. Opioids are necessary to prevent suffering, but there are risks related to potency, route of administration, and patient history,” says Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission. “By engaging in a comprehensive approach to assessment, monitoring, and patient education, opioid overuse and associated harm can be prevented.”

Mr. Federico encourages the use of standard protocols like the PPAHS PCA Safety Checklist: “Use and adherence with standardized processes for eligible patients leads to better clinical outcomes. The PPAHS PCA checklist lays out essential steps to be taken to initiate patient-controlled analgesia (PCA) with a patient and to continue to assess that patient’s use of PCA. Following these steps will help to increase patient safety and save lives.”

Michael Wong is founder and executive director of the Physician-Patient Alliance for Health & Safety (PPAHS). He is a graduate of Johns Hopkins University and is currently on the editorial board of the Journal of Patient Compliance, a peer-reviewed journal devoted to improving patient adherence. Wong is passionate about improving patient safety and health outcomes through technology like capnography, a type of patient monitoring. Wong may be contacted at

Sean Power is the community manager for the Physician-Patient Alliance for Health and Safety (PPAHS). He also blogs for a non-profit medical and research foundation, AMREF, that focuses on improving healthcare in Africa. Power cares deeply about achieving better clinical outcomes for all patients in every healthcare facility.