Kenneth Maxik, MBA, MBB, FACHE

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	As 2017 ends, there’s no doubt the opioid crisis will go down in the books as one of the foremost public health issues of the year-if not the decade.

	Drug overdoses are now the leading cause of accidental death in the U.S., and patients, emboldened by the media, have been looking for answers. Many experts have pointed to specific events, such as congressional legislation marking a “decade of pain control and research” in 2000; the Veterans Health Administration recognizing pain as a fifth vital sign that same year; and pharmaceutical companies introducing more powerful, longer-acting drugs in response; however, while these efforts to pinpoint causes are critical (those wise words of George Santayana, “those who fail to understand the past are doomed to repeat it,” apply in healthcare as well as anywhere else), it’s now time for actionable solutions.

	While the opioid epidemic is a system issue, which will require the cooperation of virtually all segments of businesses, governments, and communities to address, many healthcare leaders are asking themselves what they can do now, in their own organizations, to make an immediate impact.

	Though far from a comprehensive list, here are five opportunities may provide a running start.

Consider nonpharmacological therapy for chronic pain.

 More than 100 million Americans suffer from chronic pain (

, almost as many people (91.8 million or one in three Americans) were prescribed an opioid drug in 2015. That same year, there were more than 20,000 overdose deaths related to prescription pain relievers (

). The conclusion here is sobering: When used improperly, prescription pain medications can be deadly-and it’s easy for even the most experienced physicians and well-meaning patients to use them improperly. For many people, the quantity of opioids they need to see an effect will always increase, establishing an unsustainable, and often, dangerous pattern. There are many nonpharmacological options for those who need to manage pain over time. Alternatives to consider include, for example: heat, ice, message therapy, physical therapy, transcutaneous electrical nerve stimulation and aromatherapy. Prescribers should consider these options, carefully weighing their pros and cons against those of their opioid counterparts.

Establish realistic pain management goals. 

Before starting a treatment plan, it’s critical that physicians and their patients establish realistic goals that balance the obvious need for pain relief with other important outcomes, such as general quality of life (which can be significantly impacted by the many side effects of opioids). All parties should understand that, generally, it’s impossible to safely eliminate all pain, and in fact, a perceived pain reduction of 30% is a reasonable “win” in this area. Of course, adopting this perspective is easier said than done-a convergence of factors, including those outlined in the introduction to this article, have resulted in loosening attitudes toward prescribing opioids and a corresponding demand for total pain management – however, as a culture, and starting at an individual hospital level, we must manage our expectations, as for most patients, opioids cannot be a long-term solution.

Arguably, data are the healthcare industry’s number one defense when it comes to preventing unnecessary opioid prescription and, accordingly, misuse and/or dependence. Prescription drug monitoring programs (PDMPs), are being utilized to allow 360-degree accountability by tracking patients’ opioid use as well as the prescribing histories of doctors. When the whole patient care team has access to such a system, individual members are empowered to recognize and intervene at the first sign of problematic behaviors such as patients who are “doctor shopping” or doctors who may be unknowingly unsafe in their prescribing practices. According to the CDC, state-level use of PDMPs have already resulted in improvements in prescribing behaviors, less use of multiple providers by patients, and decreased substance abuse treatment admissions. While health leaders may historically have been conditioned to keep data close to the vest, they should be ready for such industry-wide collaboration, embracing it for the opportunities it presents for both improved patient experience and better health outcomes.

In response to the opioid crisis, industry organizations are rapidly developing new guidelines, often with stakeholder feedback, to guide healthcare leaders through an increasingly challenging environment. Healthcare leaders should assign team members in each discipline (nursing, pharmacy, providers, etc.) to monitor for the latest research and recommendations on what healthcare organizations can do to fight the opioid epidemic. For example, the 

 recently endorsed new performance measures to help physicians identify problem users and reduce their opioid prescription rates, while the 

 recently recommended that extended release or long-acting pain medication only be used for cancer pain. Good ideas may be found in a range of healthcare disciplines, and smart organizations must be committed to sourcing and combining “the best of all worlds” to make sure their organization is acting in accordance with best practices and emerging regulations.

When a patient is prescribed opioids- especially given the current climate-his or her patient care team has a responsibility to follow up and be sure he or she is continuing to use the medication responsibly. A good rule of thumb is for providers, or even pharmacists (who may have a closer relationship with patients, and be more familiar with their medications) to follow up within one to four weeks of a patient starting long-term therapy or increasing their dose, or more generally, at least every three months.  

	The opioid epidemic is a nationwide issue, touching, however indirectly, almost every individual and community in the U.S. While over the next many years, decisions must be made at the highest levels to combat the opioid crisis, healthcare leaders must remain vigilant in spotting unintended consequences as these issues were-in part-driven by well-meaning policy. In the meantime, individual healthcare leaders can and should continue to consider ways, such as the tactics listed above, they can contribute in the interim to benefit their patients, their business, and their country.

Kenneth Maxik is the director of patient safety and pharmacy compliance for 

Articles

Consider these five opportunities to help curb one of the biggest public health issues of the year.

Five ways health executives can impact the opioid crisis

	It’s human nature-everyone makes mistakes. But the consequences of those mistakes can range wildly not only according to their severity, but also depending on who commits them. When a marketer makes a typo on a press release, the worst case scenario is typically a minor loss of credibility. If a healthcare practitioner were to make the same mistake on a patient’s chart, say by accidentally prescribing clozapine instead of olanzapine (two “look-alike, sound-alike” drugs, which are often confused), the result could be catastrophic.

	Despite the fact that the healthcare industry overall takes this responsibility very seriously, the CDC estimates 250,000 Americans die annually due to medical errors.

	Of course, not all medical errors result in a patient death. In fact, many experts have suggested that the majority may have no tangible effect at all, and thus go unreported. Healthcare executives must not overlook these common, but less-serious errors. Aside from the possibility the next incidences of these errors could have more serious consequences, they also may provide critical insight into the systemic issues that allowed them to occur in the first place.

	Thus, to tackle medical errors effectively, healthcare executives should take a step back, and consider tactics that analyze and address medical errors at a system level. Here are four ways how: 

 While medical errors affect a wide variety of patients, certain patients and populations are statistically at greater risk. A peer-reviewed 

American Association of Critical Care Nurses

 identifies these groups as: patients in isolation who may receive less contact with healthcare professionals; patients with limited English proficiency who may lack the native language proficiency which is often required to interpret complex medical instruction; and patients with low health literacy who may struggle to “adequately communicate with members of the healthcare team, fill out complex forms, and understand concepts related to risk and probability.” The 45% of the U.S. population with at least one chronic disease (

), and the 35.8% of U.S. adults taking five or more medicines, a practice known as polypharmacy, according to the 

Journal of the American Medical Association

, are also at increased risk as a result of their increased touchpoints with the healthcare system-i.e., there is more 

 for error. When it comes to these groups, simple steps such as remaining vigilant, implementing safeguards (e.g., biometric verification, etc.), and improving communication may dramatically reduce medical errors. Certain work processes within a hospital are also more vulnerable to errors. For example, a recent five-hospital observational study on the accuracy of preparing small- and large-volume injectables, chemotherapy solutions, and parenteral nutrition (PN) showed a mean error rate of 9%, meaning almost one in 10 products were prepared incorrectly prior to dispensing, according to the 

. In this case, environmental changes, such as improvements to equipment or processes, may make a significant difference. 

Promote interdisciplinary collaboration. 

When it comes to medical error prevention, the most obvious, and yet most neglected, tactic are often one in the same: improving and streamlining communication among links in the patient care chain (e.g., monitoring handoffs in communication). For example, in many hospitals, pharmacists-critical allies in the prevention of medical errors-are relegated to the basement in predominantly order fulfillment roles. They have limited face-to-face interactions with their colleagues in other departments, and even less with the patients they’re working to treat. One proven tactic to address this issue is to decentralize the pharmacy, positioning pharmacists as permanent resources in particularly vulnerable hospital departments, such as the ER, or otherwise, rotating them between these departments on a regular basis. Once on the patient floor, pharmacists may provide more comprehensive patient counseling (at which time, experts suggest 

, serve as a second pair of eyes for nursing and physician staff, and oversee new automation technology (which, while designed to ultimately improve patient safety through the elimination of human error, in their transition period, can actually make hospitals more vulnerable to medical errors).

While healthcare professionals should never rely on patients and their caregivers to take an active role in reducing medical errors (after all, even if it’s in their best interest to do so, it’s not always possible due to a lack of time, awareness, or knowledge), helping them work toward this goal can have a dramatic impact. As patients and their caregivers have a clear personal investment in patient safety, they’re arguably healthcare professionals’ most critical resource in promoting it. In light of this, hospitals should make an effort to empower patients to be their own strongest advocates-providing literature with tips they may have not considered (e.g., make sure your doctor knows about medications you’re taking; for healthcare procedures, elicit vocal agreement from you, your doctor, and the person who is administering the procedure on what’s about to be done, etc.), increasing their interface with pharmacists who are best equipped to answer their questions and concerns related to their medications (a huge component of medical errors), and encouraging them to educate themselves on their condition and the different treatment options available to them.

To prevent future medical errors, it’s imperative to ensure those that have already occurred are accurately reported. Unfortunately, in an effort to promote accountability for medical errors, many hospitals have unintentionally created a “punishment” culture which discourages accurate reporting. By doing their best to target behaviors rather than individuals, healthcare leaders may help ensure staff members are comfortable coming forward with knowledge of medical errors that have already occurred, as well as opportunities for medical errors, within their organizations. Other steps, such as simplifying reporting systems to make it easy for healthcare professionals to report errors when they first occur and worry about collecting secondary details later, can also help ensure medical errors don’t fall through the cracks. Finally, engaging an objective third-party organization to track and analyze medical errors is often a good idea-not only due to their likely expertise in the area, but also because their outside perspective may allow them to catch systemic issues that those closer to the organization may have missed. All of these tactics will help hospitals collect accurate data, and then triage to address the most dangerous errors for the quickest improvement in patient safety.  

Kenneth Maxik has worked with interdisciplinary hospital teams for more than 20 years on quality, patient safety and compliance. In his role as director of patient safety at 

-a hospital pharmacy management and patient care company-he develops and annually updates a proprietary 250-point patient safety checklist for clients, including medical error measures, leveraging the data he collects to recommend protocols that improve patient safety at client facilities. 

Consider these tactics that analyze and address medical errors at a system level.

Author | Kenneth Maxik, MBA, MBB, FACHE

Articles

Five ways health executives can impact the opioid crisis

Four ways to reduce dangerous medical errors at your hospital