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Review

Opioid-Induced In-Hospital Deaths: A 10-Year Review of Australian Coroners’ Cases Exploring Similarities and Lessons Learnt

1
College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia
2
Southern Adelaide Local Health Network, Bedford Park, SA 5042, Australia
3
UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
4
SA Pharmacy, SA Health, Adelaide, SA 5001, Australia
*
Author to whom correspondence should be addressed.
Academic Editor: Jon Schommer
Pharmacy 2021, 9(2), 101; https://doi.org/10.3390/pharmacy9020101
Received: 11 March 2021 / Revised: 19 April 2021 / Accepted: 4 May 2021 / Published: 7 May 2021
(This article belongs to the Special Issue Responsible Use of Opioids)
Although opioids are the cornerstone of moderate-to-severe acute pain management they are appropriately recognised as high-risk medicines. Patient and health service delivery factors can contribute to an increased risk of death associated with excessive sedation and respiratory impairment. Despite increasing awareness of opioid-induced ventilation impairment (OIVI), no reliable method consistently identifies individual characteristics and factors that increase mortality risk due to respiratory depression events. This study assessed similarities in available coronial inquest cases reviewing opioid-related deaths in Australian hospitals from 2010 to 2020. Cases included for review were in-hospital deaths that identified patient factors, clinical errors and service delivery factors that resulted in opioid therapy contributing to the death. Of the 2879 coroner’s inquest reports reviewed across six Australian states, 15 met the criteria for inclusion. Coroner’s inquest reports were analysed qualitatively to identify common themes, contributing patient and service delivery factors and recommendations. Descriptive statistics were used to summarise shared features between cases. All cases included had at least one, but often more, service delivery factors contributing to the death, including insufficient observations, prescribing/administration error, poor escalation and reduced communication. Wider awareness of the individual characteristics that pose increased risk of OIVI, greater uptake of formal, evidence-based pain management guidelines and improved documentation and observations may reduce OIVI mortality rates. View Full-Text
Keywords: opioid; inpatient; hospital; medication safety; respiratory depression; coroner’s inquest opioid; inpatient; hospital; medication safety; respiratory depression; coroner’s inquest
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MDPI and ACS Style

Smoker, N.; Kirsopp, B.; Johnson, J.L. Opioid-Induced In-Hospital Deaths: A 10-Year Review of Australian Coroners’ Cases Exploring Similarities and Lessons Learnt. Pharmacy 2021, 9, 101. https://doi.org/10.3390/pharmacy9020101

AMA Style

Smoker N, Kirsopp B, Johnson JL. Opioid-Induced In-Hospital Deaths: A 10-Year Review of Australian Coroners’ Cases Exploring Similarities and Lessons Learnt. Pharmacy. 2021; 9(2):101. https://doi.org/10.3390/pharmacy9020101

Chicago/Turabian Style

Smoker, Nicholas, Ben Kirsopp, and Jacinta Lee Johnson. 2021. "Opioid-Induced In-Hospital Deaths: A 10-Year Review of Australian Coroners’ Cases Exploring Similarities and Lessons Learnt" Pharmacy 9, no. 2: 101. https://doi.org/10.3390/pharmacy9020101

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