December 10, 2014: An Opioid-Related Death in a Small Community Hospital
Pain management is a complex process that can involve a number of pharmacologic treatment modalities, including traditional pain medications (e.g., non-opioids and opioids) and adjunctive pharmacotherapy (e.g., anticonvulsants, antidepressants). Choosing an appropriate starting dose for an opioid, titrating opioid doses, using more than one opioid, and converting from one opioid to another are all elements of pain management wherein errors can lead to significant harm. This bulletin shares findings and recommendations from an ISMP Canada review of an unexpected death that occurred after admission to a small community hospital for management of acute pain.
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