DefinitionsHarmImpairment of the physical, emotional, or psychological function or structure of the body and/or pain resulting therefrom.

MonitoringTo observe or record relevant physiological or psychological signs.

InterventionMay include change in therapy or active medical/surgical treatment.

Intervention Necessary to Sustain LifeIncludes cardiovascular and respiratory support (e.g., CPR, defibrillation, intubation, etc.)

NCC MERP Index for Categorizing Medication Errors

No Error

Error, No Harm

Error, Harm

Error, Death

PSF030G

Category I:An error occurred that

may have contributed to or resulted in the patient’s death

Category A:Circumstances or

events that have the capacity to cause error

Category B:An error occurred but the error did not reach the patient (An "error

of omission" does reach the patient)

Category H:An error occurred that required intervention

necessary to sustain life

Category G:An error occurred that

may have contributed to or resulted in permanent

patient harm

Category F:An error occurred that may

have contributed to or resulted in temporary harm to the patient and required

initial or prolonged hospitalization

Category E:An error occurred that may have contributed

to or resulted in temporary harm to the patient and required

intervention

Category D:An error occurred that

reached the patient and required monitoring to

confirm that it resulted in no harm to the patient and/or

required intervention to preclude harm

Category C:An error occurred that

reached the patient but did not cause patient harm

©�2001 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved.*� Permission is hereby granted to reproduce information contained herein provided that such reproduction shall �� not modify the text and shall include the copyright notice appearing on the pages from which it was copied.

BACKGROUND

RESEARCH QUESTION

NCC MERP INDEX OF MEDICATION ERRORS

A Haddon Matrix Model for Prevention of Iatrogenic Opioid Overdose

Adam Janicki1, Francesca Beaudoin1, Don McKaig2, and Kavita Babu3

1Department of Emergency Medicine, Rhode Island Hospital, The Alpert Medical School of Brown University, 2Department of Medicine, Division of Clinical Pharmacology, Rhode Island Hospital,

3 Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School

METHODS

Iatrogenic in-hospital opioid toxicity results in a range of

adverse drug effects – sedation, potentially life-

threatening CNS and respiratory depression.

A structured approached is required to identify risk

factors for iatrogenic opioid overdose.

This investigation aims to identify patient, provider, and

systematic factors associated with iatrogenic opioid

toxicity in the emergency department (ED).

Can the Haddon Matrix, a well-defined injury prevention paradigm, be applied to ED iatrogenic

opioid overdose?

A case series of iatrogenic opioid overdose from a large urban academic ED was identified through query of ED electronic medical records for ED visits during 10/1/10-12/31/11.

Patients were included if they: 1) received an opioid before naloxone; 2) had an opioid-related adverse drug event (ADE); and 3) were determined to have experienced a medication error resulting in harm. ADE was defined as objective or subjective respiratory distress, sedation, or hypotension which then improved after naloxone administration

Each case was reviewed to determine category of harm and root cause of error.

Cases were assigned a category of harm based on the National Coordination Council for Medication Error Reporting and Prevention Index [NCC MERP] classification scheme.

Cases where harm resulted were used to construct a Haddon Matrix.

Utilizing the naloxone trigger tool, a total of 63 cases of iatrogenic opioid overdose were identified.

None of the patients identified using the naloxone trigger had an adverse event identified in the voluntary reporting system.

The median age was 57 (Range: 14 – 97).

42 (67%) cases were determined to have experienced harm (NCC MERP categories E – H).

Identified patient, provider (vector), and system factors were then used to construct a Haddon Matrix.

The displayed Haddon Matrix frames the actionable areas required to prevent serious opioid-related adverse drug events in the ED setting.

RESULTS

CONCLUSIONS The naloxone trigger tool successfully identified numerous cases of iatrogenic opioid toxicity.

We describe a Haddon matrix for iatrogenic in-hospital overdose, which identifies several modifiable factors.

Focused interventions for high-risk patient populations and clinical settings, and pre-/post-event provider education could be effective at reducing iatrogenic opioid overdose in the ED setting.

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HADDON MATRIX

FUNDING The Lifespan Risk Management Grant Award

Host Vector (Provider) Environment (Physical and Social)

Age Coadministration with other CNS depressants (eg. benzodiazepines)

Adequate monitoring (oximetry, capnography)

Alcohol Intoxication Failure to obtain accurate medication history Transitions of care Altered mental status (head injury,

dementia) Inappropriate use of opioid

(patient altered or hypercarbic) Communication failures

Pre-event Chronic Obstructive Pulmonary Disease No dose adjustment (hepatic, renal of geriatric) Electronic ordering and overrides

Dementia Provider fatigue Multiple providers

Obesity Provider inexperience Pharmacy monitoring

Sleep Apnea Route (IM or SC)

Familiarity with naloxone dosing Appropriate monitoring during procedural sedation

Anaphylaxis Familiarity with naloxone duration of action Appropriate monitoring after procedural sedation

Event Patient unable to participate in care Knowledge of and adherence to procedural sedation guidelines Availability of naloxone

(secondary to mental status depression) Recognition of opioid overdose Availability of resuscitative equipment

Error at delivery (wrong dose, concentration)

Hypercarbia Adequate monitoring for recurrent symptoms Need for admission or higher level of

care Adequate observation period for recurrent

symptoms Debriefing with team

Post-event Need for multiple naloxone doses Disclosure to patient Review by medication safety

Re-administration of opioids Provision of adequate discharge instructions Formalized "trigger tool" review process

Recurrent bradypnea Referral to peer review committee

Recurrent CNS depression