Don't let these terrible outcomes with IV pain meds happen on your watch

ED nurses failed to monitor their patients

A patient involved in a motor vehicle accident suffers irreversible brain damage — not from his injuries, but from an overdose of pain medication. In this case, "the ED nurse did not chart the administration of the medication, nor did she document a change in the patient's level of consciousness," says Teri J. Cox, RN, MS, CLNC, president and owner of Point Pleasant, NJ-based TCK Consulting, a legal nurse consulting firm. Cox is former director of emergency services at Bellevue Hospital/New York University Medical Center in New York City.

A lawsuit was filed, and the ED nurse, hospital, and ED physician were all found negligent for failing to respond appropriately. An $8.35 million verdict was granted.

In another case, ED nurses gave pain medications to a 39-year-old man with lower abdominal pain, who was admitted to the floor but later was discharged. He returned to the ED three hours later with sudden onset of lower abdominal pain and nausea. He was given a 100 mcg dose of fentanyl, then another 200 mcg dose an hour later. He arrested 10 minutes later. The patient was intubated and his heart rate was restored; however, he never regained consciousness and died two weeks later.

Two ED nurses were implicated in the subsequent lawsuit. The first nurse, who gave pain medications including morphine, was inconsistent about the timing of doses when giving deposition testimony. The second nurse, who gave both doses of fentanyl, claimed that he questioned the second dose with a supervisor and the ordering doctor, who confirmed the large dose was appropriate for a patient in severe pain, and he testified that he gave the dose slowly over five minutes. However, none of this was documented in the medical record. The nurse also admitted leaving the patient immediately after giving the dose to check on other patients.

Justin S. Greenfelder, JD, a health care attorney at Canton, OH-based Buckingham Doolittle, says, "The case is still pending against the hospital as the employer of the nurses, but will likely settle for mid-six figures in the near future." Greenfelder represented several ED physicians named in the lawsuit who were dismissed after the ED nurses' testimony.

There are three lessons to learn from this case, he says:

Make sure the record reflects all actions taken in administering medication.

"Accurate documentation, especially as to dosage and time, is crucial," says Greenfelder.

Anticipate potential complications.

"This patient received a lot of pain medication in a short amount of time," says Greenfelder. "The ED nurse was criticized for not staying with the patient after giving the second dose of fentanyl and potentially preventing the arrest."

Communication with physicians is crucial.

The ED nurses did not stay in contact with the ordering physician after administration of medication. "The ED physicians were thus caught off guard in treating potential complications," says Greenfelder.

Do frequent monitoring

Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN, says, "Frequent monitoring of vital signs — respiratory rate, blood pressure, heart rate, and oxygen saturation — will catch early problems."

Laurianne Asher, RN, an ED nurse at Alegent Health Lakeside Hospital in Omaha, NE, says when giving pain medications, "respiratory distress should always be anticipated and watched for. Ambu bags should always be available for use."

According to Franklin Hickey, RN, MSN, director of critical care and emergency services at Saint Peter's University Hospital in New Brunswick, NJ, respiratory depression is "the most frequent and dangerous untoward affect resulting from IV analgesics. Additional responses include a decrease in blood pressure with a concurrent elevation or decrease in heart rate, nausea, vomiting, and an allergic reaction."

Warning signs of respiratory distress or failure include decreased respiratory rate, decreased oxygen saturation, and increased lethargy, says Asher. "Supplemental oxygen therapy, analgesic reversal medication, and cardiac monitoring should be initiated," she says. "Subsequent lab work may be necessary, depending on the situation."

Check the patient for expected and unexpected outcomes every five to 10 minutes for the first 20-30 minutes, advises Katie Ryan, RN, BSN, director of the ED at St Rose Dominican Hospitals — San Martin Campus in Henderson, NV. "This will assure the patient that you are diligently working to control his or her pain," Ryan says. "It will also allow for rapid intervention of any untoward effects that may have been caused by the IV narcotic."

Do frequent rounding and watch for subtle changes, says Hickey. "If you gave the medication 30 minutes ago and you see labored respiration, that's a clear indication that you must give supplemental oxygen and immediately intervene," he says.

Continually reassess pain levels. "If initially the patient's pain level was a 9, after 30 minutes it should be around a 7, and after an hour it should be a 3 or 4," says Hickey. [See sample documentation used by Saint Peter's ED for pain assessment and reassessment - Sample 1 and Sample 2]


For more information on administration of intravenous pain medications, contact:

  • Michele Bascom, RN, Clinical Manager, Emergency Department, The Hospital of Central Connecticut, New Britain. E-mail:
  • Lam Rehfuss, RN, BSN, Nurse Manager, Emergency Services, Saint Peter's University Hospital, New Brunswick, NJ. Phone: (732) 745-8600, ext. 5091. E-mail:
  • Joan Somes, PhD, MSN, RN, CEN, FAEN, Staff Nurse/Department Educator, St. Joseph's Hospital, St. Paul, MN. Phone: (651) 232-3000. E-mail:
  • Denise Thomas, RN, Clinical Nurse Specialist, Emergency, Trauma, and Critical Care Services, Santa Rosa (CA) Memorial Hospital. E-mail:

5 must-do steps for IV narcotics

To prevent adverse outcomes with the use of intravenous (IV) narcotics, follow these five steps:

Obtain an accurate history of all medications that the patient has taken in the last six months and the time of the last dose for medications taken in the last 24 hours.

"Knowing whether the patient is opiate-naive or not will determine the amount of teaching and monitoring required before administering the medication," says Katie Ryan, RN, BSN, director of the ED at St. Rose Dominican Hospitals — San Martin Campus in Henderson, NV.

Also, Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN, says not to forget medications administered in the ambulance, "especially if the medics gave a 'heavy dose' of medication prior to arrival."

Use smaller amounts of narcotics and titrate for effect, instead of giving a rapid bolus of the total amount the physician will allow to be given.

"This helps to prevent problems," says Somes. "Our physicians are usually great at writing orders that allow us to titrate doses on the medications. For instance, we can start with 2 mg of morphine and add in 2-mg increments if the patient has not had pain relief in 15-20 minutes. Staff will recheck vital signs between doses. Sometimes the nurses will ask, 'Can I start with the smaller dose, and then add more if needed?'"

Know which patients are at high risk for problems.

Patients with hypotension, dehydration, cirrhosis, and kidney failure are at increased risk for adverse affects, says Denise Thomas, RN, clinical nurse specialist for emergency, trauma, and critical care services at Santa Rosa (CA) Memorial Hospital.

Older adult and the pediatric patient are more sensitive to narcotics, says Somes. "Simple 'eyes-on' monitoring is crucial to monitor the patient's respiratory rate," she says. "We have posted staff in the room to ensure the patient is breathing deeply and often enough."

However, any patient can be at risk for problems with pain medications, says Laurianne Asher, RN, an ED nurse at Alegent Health Lakeside Hospital in Omaha, NE. "Be aware of any allergic or nonallergic reactions previously experienced with pain medications," Asher says. "Patients who have received a high dose of pain meds and are currently receiving more pain medication, as well as patients who are on pain medication infusion pumps, are at high risk for problems."

Prevent falls.

Franklin Hickey, RN, MSN, director of critical care and emergency services at Saint Peter's University Hospital in New Brunswick, NJ, says that because pain medications might alter your patient's mental status, consider these precautions: Putting the side rails up, having the call bell in reach, placing your patient closer to the nurses' station, and ensuring they don't walk independently.

Have analgesic reversal medications readily available.

When a patient arrived at Alegent Health Lakeside's ED in respiratory distress, nurses noticed a fentanyl patch applied to her back. "We removed it promptly and administered [naloxone] to reverse the medications she had previously received at the nursing home facility," recalls Asher. "Oxygen therapy was administered, and the patient's respiratory status and oxygen levels returned to normal."

Should pain meds be given orally, IV, or IM?

The etiology of the pain. The reported severity. The patient's age and level of mentation. The plan of care. These are all factors that determine whether your patient's pain medication will be given orally, intramuscularly, or intravenously, says Denise Thomas, RN, clinical nurse specialist for emergency, trauma, and critical care services at Santa Rosa (CA) Memorial Hospital.

"A patient's physiologic response to pain may alter their hemodynamic, respiratory, cognitive, and emotional status," says Thomas. "Therefore, it is important to decrease pain to a tolerable level as rapidly and safely as possible."

Patients in severe pain from fractures, cardiac pain, kidney stones, or abdominal pain are often given IV analgesics as these provide the most rapid pharmacological onset, says Thomas. "Patients who have received fentanyl have reported a decrease of pain within minutes," she says. Onset of oral analgesics properties are reported as early as 30 minutes or as long as 60 minutes, depending on the timing of the patient's last meal, says Thomas. "Oral medications, although they may provide a longer duration of analgesia, have a longer onset."

Has your patient had the drug you're about to give?

Also, ask patient their pain baseline

Here's an important question to ask your patient before giving pain narcotics, says Michele Bascom, RN, clinical manager of the ED at The Hospital of Central Connecticut in New Britain: "Have you had this medication before?"

"We usually wear people out asking about allergies before medication delivery," she says. "But if the patient has not had a particular medication, especially a narcotic, this can heighten awareness for potential problems."

Another important question to ask is about your patient's pain baseline. If your patient tells you her pain level is a 3, you might assume she needs more pain relief, but this isn't always the case.

"We have oncology patients that are never pain-free, so a baseline for them might be a three," says Lam Rehfuss, RN, BSN, nurse manager of emergency services at Saint Peter's University Hospital in New Brunswick, NJ. "If your patient says their pain is a 10 right now, your next question should be, 'Well, what is your pain normally?' Each individual is different."

Patients with chronic illnesses such as sickle cell disease may require very high doses of intravenous pain medication to get their pain under control, notes Franklin Hickey, RN, MSN, director of critical care and emergency services at Saint Peter's. "We find ourselves constantly battling with that population," he says. "You want to care for the patient, but you also worry about giving them too high a dosage. That is a real challenge."

Hydration is an important part of alleviating the sickle cell patient's pain, says Hickey. "The key with sickle cell is you want to hemodilute the blood by giving large amounts of fluid," he says.