Table 1

Underlying Causes of Opioid-Induced Oversedation and Respiratory Depressiona

DeficiencySpecific Causes
Knowledge deficits• Danger of sustained-release opioids in opioid-naive patients; lack of understanding of definition of opioid naive
• Too-rapid dosage escalation, including extended-release formulations
• Multiple opioids used simultaneously
• Sedation as a precursor for respiratory depression
• Consideration for dosage reduction when converting from one opioid to another
Inadequate sedation monitoring• Different scales in use; none developed specifically for opioids
• No uniform policy and practice on frequency of assessments or action steps to be taken for sedation
Other practices• Transferring sedated patients from postanesthesia care unit to general surgical floors
• Opioid doses administered before transfer
EMR deficiencies• No opioid conversion table easily available from within the EMR
• No prescriber warnings about patient risk factors, use of long-acting opioids, and concomitant use of sedating medications
• Information on pain scores, doses administered, and sedation levels located in multiple areas of EMR
Cultural issues• Clinical culture stressed the elimination of pain or the achievement of a pain score below an arbitrary number
• No culture or practice for consideration of sedation levels during multidisciplinary rounds
  • a EMR = electronic medical record.