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Errors related to extended-release opioids and COVID-19 vaccines warrant attention and should be a priority.
Even as health care providers and patients continue to battle the coronavirus disease 2019 (COVID-19) pandemic and its accompanying challenges, medication safety issues.
Here we focus on 2 issues that warrant attention and priority to mitigate risks. These are errors and hazards that have been persistent but can be avoided or minimized with system and practice changes.
Extended-Release Opioids
Inappropriate prescribing of extended-release (ER) opioids to opioid-naïve patients has resulted in serious harm and death. The Institute for Safe Medication Practices (ISMP), as well as the FDA, have warned practitioners about this well-known problem for decades. However, inappropriate opioid prescribing continues to occur, often because of a knowledge deficit about the dangers associated with prescribing ER opioids to opioid-naïve patients and/or not understanding the difference between opioid-naïve and opioid-tolerant. For example, in 2020, the ISMP published several new reports related to prescribing fentanyl patches to elderly, opioid-naïve patients, sometimes to treat acute pain or because of a codeine “allergy” that was a minor drug intolerance.1 Fentanyl patches should be prescribed to opioid-tolerant patients only for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment. This is so critical to safety that, in 2018, the ISMP called for the elimination of prescribing fentanyl patches to opioid-naïve patients and/or patients
with acute pain in the ISMP Targeted Medication Safety Best Practices for Hospitals.2 In 2020, this best practice was incorporated into a new best practice to verify and document the patient’s opioid status and type of pain before prescribing and dispensing ER opioids. Here are some best practices:
COVID-19 Vaccines
Findings from the analysis of recent influenza vaccine errors can be used to prevent mistakes during the COVID-19 vaccine campaigns that started in December 2020. Common contributing factors associated with flu vaccine errors that could also be risk factors for COVID-19 vaccinations include dilution or mixing errors; look-alike vaccine names, labels, and packaging; not checking or documenting administration in the immunization information system; and unsegregated freezer or refrigerator/storage.3 Two other vaccine error–related contributing factors often reported to the ISMP are communication barriers with patients and temperature excursions, and they may also affect COVID-19 vaccination efforts.
The ISMP also reviewed early COVID-19 vaccine errors voluntarily reported to its ISMP National Vaccine Errors Reporting Program.4 Numerous dilution errors with the Pfizer-BioNTech vaccine have led to overdoses when too little diluent was used, often 1 mL instead of 1.8 mL. In 2 cases, patients received the entire vial contents without dilution. In a clinic, patients received intramuscular injections of Regeneron’s monoclonal antibody casirivimab instead of the Moderna COVID-19 vaccine because of vague labeling of the monoclonal antibody, which included a product code name, not the established name. Wasted vaccines from inefficient scheduling or no-shows were reported, as was administration of the vaccine to patients younger than indicated.
Here are some things to keep in mind:
AUTHOR BIO
Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.
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