Improving Patient Safety for Patients on Opioid Medications: Revising the Verification Process

The need for medication safety is paramount for all patients, especially those prescribed opioids in the pediatric population. Electronic documentation can play a substantial role in safe administration practices; however, caution must be taken to assure that the clinical practice components essential to safety are not lost in the transition. One Midwestern pediatric hospital recently implemented a new electronic documentation system. By design, two registered nurse signatures were required for opioid waste verification, as was previous practice. However, two signatures for verifying dosages and pump programming, which also were previously required, were no longer necessary. Although two RNs were still needed to verify dosages and programming, many nurses misunderstood this lack of signature requirement as no need for a verification check at all. Using patient-controlled analgesia (PCA) incident reports, the institution's PCA Task Force identified that most PCA errors could have been prevented with proper verification by two RNs.