Safer Opioid Dispensing Practices Help Prevent Tragedies

medication safety analyst says preventive measures can reduce the risk of common, life-threatening errors involving concentrated opioid oral solutions.

Pharmacy Times.

Pharmacy Times

PLAINSBORO, NJ (May 3, 2010)—Overdoses of concentrated opioid oral solutions are often the result of a simple prescribing or pharmacy error, according to a new report in the April 2010 issue of Thereare steps health professionals can take to avoid them.In the article “Preventing Errors with Concentrated Opioid Solutions,” columnist and medication safety analyst Michael J. Gaunt advocates practical changes prescribers and pharmacists should implement to safeguard patients from the potentially devastating consequences of an incorrect dose of these powerful pharmaceuticals.

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Gaunt, also the editor of says even the location of these products on pharmacy shelves can cause confusion that ends in an error. Measuring and labeling mix-ups—for example, physicians who prescribe medications in milliliters instead of milligrams—have resulted in patients receiving doses of morphine that were 20 times the amount prescribed. Gaunt cites the haunting story of a patient who received a 100-mg dose of morphine instead of the prescribed 5-mg dose. The man suffered organ failure, entered into a coma, and required mechanical ventilation.

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published by Intellisphere under parent company MJH & Associates, features a medication safety article in each issue as part of its larger mission of providing “Practical Information for Today’s Pharmacist.” “Medication safety issues are often where pharmacists can have the biggest impact on healthcare,” says Mike Hennessy, Chairman and CEO of MJH & Associates. “It’s also one of the most important areas in which communication and coordination between the pharmacist and the prescribing physician is essential.”

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In the April issue of , Gaunt explains how pharmacists can reduce such errors by rethinking pharmacy storage and organization, optimizing pharmacy workflow systems, standardizing units of measurement, and instituting more comprehensive labeling and alert systems. First and foremost, Gaunt urges pharmacies to “educate staff about the potential for errors with opioid liquids and why such errors occur.”

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By studying and implementing 14 best practices outlined in and encouraging compliance from local physicians, pharmacy staff can promote the safe use of these medications in their communities and prevent tragedies caused by simple, preventable mistakes.

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Pharmacy Times

Pharmacy Times

is a clinically-based, monthly journal providing practical information pharmacists can use in their everyday practice. Each issue contains articles and features covering medication errors, drug interactions, patient education, pharmacy technology, disease state management, patient counseling, product news, pharmacy law, and specialty pharmacy. is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of free continuing pharmacy education.

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