EXECUTIVE SUMMARY

A review of closed claims related to opioid use underscores the need for good processes that minimize the risk of abuse. Risk managers should assess how their organizations adhere to opioid prescribing guidelines.

  • Many physicians do not understand their responsibility in complying with opioid prescribing guidelines.
  • Specialty physicians often assume the primary care doctor will handle opioid prescribing processes.
  • Tapering and discontinuation should be explained to the patient from the start.

The opioid crisis continues to create increased liability risks for healthcare providers, who must contend with more scrutiny over prescribing and management practices. A review of closed claims indicates hospitals and physicians can improve the way they follow guidelines and processes designed to reduce the risk.

The sharp increase in opioid use has led to a high number of addiction and severe injuries, according to a report from Coverys, a Boston-based medical professional liability insurance provider. The report is based on an analysis of closed opioid-related malpractice claims over a five-year period.

These are some findings from Red Signal Report — Opioids:

  • 51% of events involved a high-severity patient injury and accounted for 85% of indemnity paid;
  • 43% of events had root-cause factors related to medication screening and prescribing;
  • 25% of events had root-cause factors related to monitoring and management;
  • 23% of events had root-cause factors related to dispensing and administering.

“The opioid epidemic in the United States has become pervasive throughout our communities, and addressing it has proven to be very challenging. Caught in the middle of this crisis are healthcare providers,” the report authors wrote. “Many have been accused of prescribing practices that fuel addictions. From 1999 to 2017, the opioid epidemic in the United States contributed to the deaths of over 700,000 people; the number of opioid-related overdose deaths was six times higher in 2017 than in 1999.” (The report is available online at: https://bit.ly/2QvjRsu.)

Multistage Process

Addressing the opioid crisis and the potential liability that can flow from it requires action at every stage of the prescription process, says Ann Lambrecht, RN, BSN, JD, FASHRM, senior risk specialist with Coverys in Charlotte, NC.

The Coverys analysis indicates risk managers should assess risk factors and safety vulnerabilities within the pain management process proactively, Lambrecht says. The assessment should include a review of internal processes related to opioid screening, prescribing, dispensing, administration, monitoring, and management, Lambrecht says.

Prevention of drug diversion is another concern, she says. Tapering and discontinuation of opioids has become more important as the medical community realizes the risks of opioid use, Lambrecht says. Physicians should discuss tapering and discontinuation with patients from the start so that they understand the medication only can be used for a limited time, she says, establishing in the patient’s mind that there will be an end date.

The Coverys report includes these recommendations on tapering and discontinuation for hospitals and other facilities:

  • Ensure prescribers understand and comply with recommendations for discontinuation;
  • Ensure two authorized healthcare providers resolve discrepancies within the same shift or business day;
  • Require lock boxes are in all areas where opioids may be left unattended;
  • Create a process for wastage of opened, unused opioids;
  • Ensure the hospital participates in a drug disposal program that complies with state and federal laws and guidelines;
  • Require discontinued opioids to be returned to the pharmacy within a defined time frame.

Each Step in Process Is Important

Risk managers must address all steps in the process, Lambrecht says. “It’s not just one thing to focus on. We used to think it could be isolated to one area of the medication process, but now we are seeing that there can be fall-downs in every single stage of that process,” Lambrecht says. “More than half the events in this study involved errors that occurred in more than one stage of care.”

Not everyone is involved in each stage of care, so communication is paramount, Lambrecht says. Clinicians also must understand that an error in one stage of care can affect the other stages, she says.

“It’s easy to find ways for everyone else to change their processes and practices, but that is a very slippery slope. If everyone involved doesn’t stay on top of every single phase of care, there are going to be problems,” she says.

Lambrecht cites an example from the report involving a physician who prescribed long-acting hydrocodone to a patient on an initial office visit without realizing the patient was taking oxycodone already. That error occurred because of failures involving screening, prescribing, monitoring program databases, and medication reconciliation, Lambrecht explains.

Other examples involve patients with comorbid conditions, which should prompt extreme caution in prescribing, and failure to follow postadministration guidelines, she says.

“Another area where we have looked very closely in terms of our data and recommendations is how prescribers often do not realize what their own responsibilities are,” Lambrecht says. “Physicians who do procedures and prescribe for a very short period of time, like orthopedic surgeons, may not realize that a patient can become dependent and addicted within five days. If they don’t do the upfront work about screening, assessing, medication reconciliation, and checking the prescription drug monitoring database, they can get into trouble because they think these patients will soon go back to their primary care physicians and it’s not their responsibility.”

Guidelines Available From CMS, Others

Guidelines from the Centers for Medicare & Medicaid Services (CMS), the CDC, and many specialty colleges offer direction on opioid prescribing, but Lambrecht says a disconnect can occur between clinicians and hospitals or health systems when it comes to who is ensuring compliance with guidelines. Physicians and administrators should proactively address the issue by agreeing on what guidelines are to be followed, and who is responsible for ensuring compliance, she says.

“Many times, physicians just don’t know what the CMS guidelines are, and they assume the hospital is taking care of that. Then, you talk to the hospital and they’re assuming the physicians are checking the drug monitoring database because they’re the ones who are prescribing,” Lambrecht says. “A good start is to perform an assessment of what current practices are so you can see if there is a gap. Most hospitals have few precautions in place, and there is usually a lot of room for improvement.”

For example, the hospital and physicians should determine who is responsible for each step in the process. Will patient screening be solely the responsibility of the prescriber, or does the hospital have some responsibility in that step? That question should be answered for every step of the process so that nothing slips through the cracks, Lambrecht says.

“You also need monitoring of those practices and real-time feedback. A lot of times, if physicians don’t hear otherwise, they will assume they are doing a great job,” she says. “Physician offices need special attention because these locations account for more than 80% of indemnity related to opioid prescribing. Also. remember that half of all opioid events involve a high-severity patient injury, including patient death. Those high severity events account for 85% of all indemnity payments.”

Risk managers overseeing affiliated physician practices should make a point of educating physicians about what guidelines apply and what resources are available, she says.

“In particular, it is important to help them understand that this is the prescribing physician’s responsibility, not just the primary care physician’s. They can collaborate with primary care physicians, but the prescribing physician should perform the screening, and take all the other steps to make sure that the process is being followed all the way through,” Lambrecht says.

SOURCE

  • Ann Lambrecht, RN, BSN, JD, FASHRM, Senior Risk Specialist, Coverys, Charlotte, NC. Phone: (800) 225-6168. Email: coverys@pancomm.com.