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Opioid Use In Hospitals, Preventing Accidental Overdose: Sentinel Event

Serious life threatening side effects caused by opioid therapy during hospital admission becomes a sentinel events for Joint Commission.1

Sentinel Event Alert are published by Joint Commission in perspective and internal memo.2 The information is shared with all the members who are certified by JCAHO.

Opioid Use In Hospitals, Preventing Accidental Overdose: Sentinel Event

Safe Opioid Use In Hospital 2

  • Opioid use is generally considered safe for most individuals.
  • Opioid therapy causes several side effects when dosage guidelines are not followed.
  • Opioids are used as an intravenous analgesics and oral analgesics in hospital.
  • Opioid side effects are closely monitored during hospital admission and stay.

Opioid Side Effects-

List Of Opioids Prescribed In Hospital For Pain-

  • Fentanyl
  • Hydrocodone
  • Methadone
  • Morphine
  • Hydromorphone
  • Oxycodone

Sentinel Alerts in Hospital: Opioid Therapy

The Following Problems Can Raise Sentinel Alerts In Hospital-

  • Inadequate pain relief
  • Opioid allergies history was ignored
  • Opioid dependent patient given inadequate or excessive pain medications
  • Opioid prescription to patient with history of opioid addiction
  • Opioid withdrawal ignored or not diagnosed
  • Death caused by opioid over dosage.

The Sentinel Alert

  • Opioid Related Hospital Sentinel Alert- This is one of the above mentioned events that occur in hospital while patient is admitted.
  • Report- Report is published by joint commission.
  • Sharing of Sentinel Alert Report- Joint Commission shares the ocurance of serious events in a hospital with all its members.
  • Aim Of The Report- The sentinel alert focuses on safe use of opioid during hospital admission.
  • Sentinel Events- During hospital admission if fatal or serious side effects occurs, which may or may not be because of negligence, then the event is considered as a sentinel events.
  • Hospital Sentinel Events- Most of the sentinel events occur in hospital emergency department and during admission for pain management.
  • Opioid Overdose- Patients are prescribed opioid in ER not knowing if the patient is taking pain medications at home or is addicted to opioids.
  • Inadequate History- Severe injury or life threatening complications results in focusing treatment on more serious problem. The clinical staffs may not obtain or realize the history of opioid consumption prior to ER admission.
  • Intravenous Opioids- Intravenous opioid for pain may result in sleep apnea or respiratory depression resulting life threatening events.

Sentinel Reports On Opioid Related Deaths

  • Joint Commission Sentinel Event database of fatal cases in hospital between 2004-2011 suggests about 47% were due to wrong dosage, about 29% were due to inappropriate monitoring of patient, and about 11% were due to other causes.
    The other causes were disproportionate dosing, medication interaction, and adverse reactions.
  • These reports highlight the need for careful and safe prescribing, monitoring and administration of opiates during hospital admission or ER visit.

Life Threatening Opioid Complications

  • Respiratory Depression-
    • Opioid depresses respiratory centers in higher dosage or when given frequently during hospital admission.
    • Incidence is higher than reported.
    • Higher incidence are noted during clinical trial.
  • Sleep Apnea
    • Mostly observed when opioids are prescribed while patient is taking sedatives or muscle relaxants.
    • Sleep apnea is secondary to respiratory depression caused by opioids, the effect is enhanced by sedative effects of adjuvant medications.

Preventing Accidental Overdose of Opioids In Hospitals:

  • The Safe Use Of Opioids3 Opioid overdose is prevented in hospital setting by accurate pain assessment and then treatment of pain with appropriate pain medications.
  • The Joint Commission’s Pain Management Standard- JCAHO standard and publications has increased awareness of the importance of safe and effective pain management.
  • JCAHO Standard of Pain Management-
    • Instituted in 2001, these standards have made a significant difference in appropriate pain management.
    • Before the standards, there were continuing reports of inadequate pain control for postoperative and traumatic pain, cancer pain, and many other acute and chronic pain challenges.
  • Safe Dispensing Of Opioid Medications-
    • Record keeping and prevention of therapeutic error has reduced the events of sentinel alerts.4
    • Life threatening events and diversion of opioids within the hospital are prevented by dispensing tamper-resistant opioid products.4
  • Compliance With JCAHO Standard-
    • Hospitals are certified of good standing by JCAHO periodically after detailed survey and visits.
    • JCAHO officers look for hospital compliance with standards set by JACHO.
    • Compliance includes appropriate assessment and management of pain.


  1. The Joint Commission and the FDA take steps to curb adverse events related to the use and misuse of opioid drugs.
    ED Manag. 2012 Oct;24(10):112-6.
  2. Safe use of opioids in hospitals.
    Sentinel Event Alert. 2012 Aug 8;(49):1-5.
  3. New Alert promotes safe use of opioids in hospitals.
    Jt Comm Perspect. 2012 Nov;32(11):11-5.
  4. Reduced abuse, therapeutic errors, and diversion following reformulation of extended-release oxycodone in 2010.
    Severtson SG1, Bartelson BB, Davis JM, Muñoz A, Schneider MF, Chilcoat H, Coplan PM, Surratt H, Dart RC.
    J Pain. 2013 Oct;14(10):1122-30.

Also Read:

Pramod Kerkar, M.D., FFARCSI, DA
Pramod Kerkar, M.D., FFARCSI, DA
Written, Edited or Reviewed By: Pramod Kerkar, M.D., FFARCSI, DA Pain Assist Inc. This article does not provide medical advice. See disclaimer
Last Modified On:September 23, 2021

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