Abstract

EVERY DAY IN hospitals nationwide, patients undergo surgery and receive large amounts of opioids for unrelieved postoperative pain, subsequently experiencing life-threatening opioid-induced respiratory depression. Based on the Joint Commission 2004 to 2011 database of reported opioidrelated sentinel events, 47% of reported events were the result of a wrong dose, 29% from improper monitoring, and 11% due to other factors such as excessive dosing, medication interactions, and adverse effects. In its sentinel event alert, the Joint Commission underscored the need for hospital staff to focus on safe opioid administration and vigilant monitoring of the effects of opioids.

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