Threats to Narcotic Safety-A Narrative Review of Narcotic Incidents, Discrepancies and Near-Misses Within a Large Canadian Health System.
Chantelle Bailey, Lianne Jeffs
PMID 34229483WHAT IT FOUND
Most narcotic incidents in this hospital involved wrong doses, count discrepancies, or the wrong drug.
Hydromorphone and morphine were implicated most often, with errors frequently occurring during shift handovers or due to workload pressures and documentation failures.
Key findings
01Incorrect dosing, narcotic count discrepancies, and wrong drug administration were the most common incident types.
02Hydromorphone and morphine were involved in the majority of reported incidents, occurring mostly in Surgery, Oncology, and Critical Care.
03Contributory factors included active failures like not reviewing medication orders, communication errors during handovers, and workload constraints.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study relied on voluntary incident reporting, which is prone to underreporting and selection bias. Patient charts were not reviewed to verify outcomes or contributory factors, so data relied entirely on reporter narratives. The incident reporting system had limitations, such as non-mutually exclusive categories and a lack of mandatory fields for clinical indications. Findings are context-specific to one academic health sciences center in Ontario and may not generalize to other settings.
Declared interests
The authors declared no conflicts of interest. The work was funded by a Health System Impact Fellowship jointly funded by the Canadian Institute for Health Research, MITACS Elevate, and the Canadian Nurses Association.
The easy way to misread this
Do not assume these findings represent the total number of narcotic incidents in a hospital. The study analyzed voluntary reports, which are known to be underreported, so the actual frequency of errors is likely higher than what is shown here.