Statement on Preventing Harm from Oversedation

Oversedation results when the level of the patient’s sedation is greater than the desired therapeutic level of sedation. It can be associated with significant actual or potential patient harm such as respiratory depression, falls, and aspiration. The risk of oversedation is present in all patients receiving opioids, other respiratory depressants, or sedating agents. In particular, four medications (morphine, fentanyl, hydromorphone, and meperidine) are disproportionately involved in harmful medical errors. In addition, a number of agencies have issued alerts and advisories regarding the risks associated with dose confusion between hydromorphone (Dilaudid) and morphine.

The Oregon Patient Safety Commission has published the Statement on Preventing Harm from Oversedation as a starting point for hospitals to use in efforts to decrease patient harm associated with sedation. The statement is consistent with The Joint Commission’s recent Sentinel Event Alert, Safe Use of Opioids in Hospitals (2010).

Factors that contribute to the risk of adverse events from oversedation are numerous and varied, encompassing both patient and health system factors. Among the health system factors are variations in medication availability, differing physician preferences, changing manufacturer doses, and inconsistent monitoring practices. Surgical patients, particularly those with serious undiagnosed obstructive sleep apnea (OSA), are at risk when receiving potent analgesics following anesthesia.

Oversedation Prevention Statement

Statement on Preventing Harm from Oversedation in Adult Hospitalized Patients

Appendices

Each of the appendices from the Statement on Preventing Harm from Oversedation in Adult Hospitalized Patients is available as an individual document for ease of use.

• Appendix A - STOP-BANG Patient Questionnaire (Microsoft Word)

• Appendix B - Patient Care Considerations for Hospitalized Adults Requiring Opioid Therapy

• Appendix C - Sleep Apnea Risk Guide to Assess Suitability for Outpatient Surgery Patients

• Appendix D - Pasero Opiod-Induced Sedation Scale (POSS) with Interventions (Microsoft Word)

• Appendix E - Richmond Agitation - Sedation Scale (Microsoft Word)

• Appendix F - Pain Management Protocol Content

• Appendix G - Protocol: Peri-operative Obstructive Sleep Apnea (OSA) Monitoring

• Appendix H - Report Guideline (Microsoft Word), an SBAR format example

Oversedation Workgroup

This statement was the result of a multidisciplinary workgroup convened by the Oregon Patient Safety Commission. The workgroup’s charge was to identify strategies that could be shared with all Oregon hospitals to decrease the risks associated with opioids and other sedating medications. Workgroup contributors included pharmacists, physicians, nurses, quality specialists, respiratory therapists, anesthesiologists, and a sleep specialist who addressed specific risks in surgical patients with obstructive sleep apnea (OSA). A complete list of contributors can be found in the statement.

Disclaimer: All data and information provided on this website is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed. The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations.