An Opioid-Related Death in a Small Community Hospital

Pain management is a complex process that can involve a number of pharmacologic treatment modalities, including traditional pain medications (e.g., non-opioids and opioids) and adjunctive pharmacotherapy (e.g., anticonvulsants, antidepressants). Choosing an appropriate starting dose for an opioid, titrating opioid doses, using more than one opioid, and converting from one opioid to another are all elements of pain management wherein errors can lead to significant harm. This bulletin shares findings and recommendations from an ISMP Canada review of an unexpected death that occurred after admission to a small community hospital for management of acute pain. The system vulnerabilities identified during this analysis likely exist in other facilities, and all those affected by this case sincerely hope that the learning shared here will lead to system improvements in hospitals across Canada.