Start Date

5-3-2024 9:10 AM

End Date

5-3-2024 11:00 AM

Description

Background of Case

  • Patient with active substance use (reported snorting 8-10 bags of fentanyl/day) not initially interested in MOUD admitted to TJUH for severe sepsis due to empyema
  • Placed on hydromorphone PCA with scheduled oxycodone for pain control and withdrawal, found to have diverted prescribed opiates and used recreational fentanyl while inpatient

Project Aim

  1. Perform root cause analysis of safety event
  2. Develop solutions to prevent similar instances in future given growing opiate epidemic in Philadelphia

Keywords

quality improvement, patient safety, opiate use

Comments

Presented at the 2024 Jefferson Health Equity and Quality Improvement (HEQI) Summit.

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May 3rd, 9:10 AM May 3rd, 11:00 AM

Patient Safety Case Review: Inpatient Use of Recreational Opiates

Background of Case

  • Patient with active substance use (reported snorting 8-10 bags of fentanyl/day) not initially interested in MOUD admitted to TJUH for severe sepsis due to empyema
  • Placed on hydromorphone PCA with scheduled oxycodone for pain control and withdrawal, found to have diverted prescribed opiates and used recreational fentanyl while inpatient

Project Aim

  1. Perform root cause analysis of safety event
  2. Develop solutions to prevent similar instances in future given growing opiate epidemic in Philadelphia