Identifying Potential Causes of Opioid Toxicity Necessitating a Rapid Response Team Visit

Background: Opioids are labeled as high-risk medications because of their propensity to cause significant harm or toxicity to patients if used inappropriately. Many incidents of opioid toxicity are the result of preventable causes. Objective: To identify and report the frequency and potential causes of opioid toxicity in the acute care setting. Methods: This single-center chart review evaluated patients receiving naloxone for presumed opioid toxicity from January 2008 through July 2010. Patients were identified for this study using rapid response team charted visits. Charts were then reviewed for opioid medications administered, possible causes of opioid toxicity, signs and symptoms of opioid toxicity, patient location by hospital floor, and prescribing physician service. Results: One hundred twenty-nine incidents of opioid toxicity met inclusion criteria and were placed in 1 or more of the applicable categories for possible causes: administration of multiple opioids (43.4%), medication errors (31.6%), and the administration of morphine to patients with impaired renal function (7.2%); 17.8% of the causes were unknown. Conclusions: Most cases of opioid toxicity were determined to be the result of preventable causes. Prevention strategies for opioid toxicity should consist of educating health care professionals as well as incorporating health information technologies shown to reduce errors. Specific areas of focus should include opioid equianalgesic dosing strategies, removal of duplicate opioid orders, and writing of clear administration guidelines for orders of as-needed opioids or multiple dosage forms of opioids.