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Long-acting concerns

COHEN, MICHAEL R. RPH, MS, ScD

MEDICATION ERRORS: EPIDURAL INJECTION
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President of the Institute for Safe Medication Practices

A new extended-release morphine sulfate solution (DepoDur) that's administered by epidural injection relieves postoperative pain for about 48 hours. But the once-and-done approach poses challenges because no infusion device or continuing orders remain to signal that the patient has received the drug. Potential problems include:

  • oversights in postoperative monitoring. The presence of an epidural catheter or patient-controlled analgesia pump would prompt nursing attention, but these devices aren't necessary once DepoDur is injected. The patient should be closely monitored for at least 16 hours after drug administration for serious adverse reactions such as oversedation or respiratory depression.
  • risk associated with another epidural injection. Injecting medication into the epidural space would increase intracranial pressure, so epidural injections should be avoided for at least 48 hours.
  • risk of additive effects if the patient receives another central nervous system (CNS) depressant during DepoDur's 48-hour effective period. Because he's at greater risk for serious adverse reactions such as respiratory depression, hypotension, and profound sedation or coma, he needs vigilant monitoring. Even traditional pain medications such as hydromorphone could cause excessive sedation or additive CNS effects.

The risks of DepoDur could be reduced by creating a preprinted order form clearly stating, Patient received DepoDur at ___(time) on ___(date), with bold warnings that the Patient should NOT receive other pain medications, CNS depressants, or epidural drugs without the anesthesiologist's consent. The form should also include parameters for appropriate monitoring.

Other safeguards are to let only anesthesia staff order opioids during the 48-hour postoperative period and to program the order entry system to raise an alert if another opioid is prescribed within 48 hours.

Finally, an alert on the patient's medication administration record and stickers over his door or bed could alert the staff not to administer opioids during DepoDur's 48-hour effective period.

The reports described in Medication Errors were received through the USP-ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at http://www.ismp.org or the United States Pharmacopeia (USP) at http://www.usp.org. You can also call ISMP at 1-800-FAIL SAFE or send an e-mail message to ismpinfo@ismp.org.

© 2005 Lippincott Williams & Wilkins, Inc.