Patient Safety Tip of the Week

February 26, 2007            Unintended Consequences


Those of you who are participating in IHI’s “5 Million Lives Campaign” likely are focusing on preventing harm from high-alert medications. If you are not, you should be – even if you are not officially participating in the campaign. One of the suggested changes to improve management of narcotics is to make available protocols and reversal agents that can be administered without additional physician orders. Given the frequency with which unintended respiratory depression (or other side effects) occurs secondary to narcotics, such protocols undoubtedly will prevent harm in almost every hospital or ambulatory surgery/procedure center.


However, we have now seen several cases where Narcan, administered by a nurse under such a protocol, actually precipitated an acute narcotic withdrawal syndrome. In each case, the patient had been on long-standing narcotic treatment (eg. for cancer-related pain) and had received an intravenous narcotic as part of conscious sedation for a procedure, resulting in respiratory depression. The Narcan administration was successful at reversal of the respiratory depression. However, the patients developed a very painful, uncomfortable state that was not immediately recognized as a withdrawal state.


The take-home lesson here is to build into your narcotic reversal protocol a provision for monitoring for an acute narcotic withdrawal syndrome in those patients who had previously been narcotic-dependent. The chance of this occurring is very small compared to the large number of patients who will benefit from a narcotic reversal protocol. But you need to keep this unintended consequence in mind as you develop those protocols at your facilities.









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