Preventing Patient Harm from Opioids in Hospitals

PLYMOUTH MEETING, PA—The opioid epidemic is clearly one of the top public health concerns in the country. Rarely, though, do news stories address the safety risks from opioids used by patients in hospitals. Despite the focus on appropriate use of opioids for pain management, many hospitals continue to see adverse events in which patients are injured by unintentional overdoses.

Now, a more detailed picture of the risks related to opioid use in acute care is emerging, based on in-depth analysis of 7,218 events reported to ECRI Institute Patient Safety Organization (PSO). The events were submitted voluntarily over a three-year period and may represent only a small percentage of all opioid-related events occurring at organizations.

ECRI Institute PSO, widely considered the largest federally certified PSO, today announces its findings in a new study, Deep Dive™: Opioid Use in Acute Care. The report looks in-depth at opioid-related patient safety events and profiles what healthcare leaders are doing to prevent harm.

“It’s a deep concern that we continue to see so many opioid-related events, including patient deaths, reported into our PSO database,” says Bill Marella, ECRI Institute executive director of PSO Operations and Analytics. “While opioids play a useful role in treating pain, the risks that come with them require that safeguards be put in place to stop misuse or overuse.”

Key findings from analysis of patient safety events:

  • Events involving problems with medication administration (35%) or drug diversion (28%) were the most frequently reported types of events.
  • Events involving problems with prescribing and patient monitoring were reported less frequently, but were more often associated with harm.
  • Harm occurred in 1 in 5 event reports that indicated the level of harm.

Patients receiving opioids in the hospital are at risk for respiratory depression, which can be fatal if not recognized and treated promptly. The Deep Dive report makes specific recommendations for monitoring strategies that can identify patients in the early stages of respiratory depression. There are also opportunities for more advanced clinical decision support to help ensure appropriate patient assessment and reduce the chances of errors in prescribing or administration.

“The good news is that there are many realistic opportunities to improve the safety of opioid use in hospitals,” Marella added.

The executive brief and an interactive slideshow about ECRI Institute PSO Deep Dive™: Opioid Use in Acute Care are publicly available with registration at The comprehensive report is available to ECRI Institute PSO and partner PSO members online; nonmembers can purchase a PDF of the report later in the year.

Marella will be presenting key findings from this report on Tuesday, October 17, 2017, at the American Society for Healthcare Risk Management (ASHRM) 2017 conference in a keynote panel, Prescriptions for Safer, More Effective Opioid Use—An ASHRM and ECRI Institute Expert Panel.

For questions about this topic, or for information about purchasing the report, please contact ECRI Institute PSO by telephone at (610) 825-6000, ext. 5558; by e-mail at; or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA.

Social Sharing

  • Potentially fatal #opioid related events in hospitals uncovered in @ECRI_Institute #Ptsafety report
  • Key finding @ECRI_Institute report–Harm occurred in 1 in 5 #opioid event reports

About ECRI Institute
For nearly 50 years, ECRI Institute’s work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. ECRI Institute PSO is a component of ECRI Institute, a nonprofit 501(c)(3) organization dedicated to improving the safety, quality, and cost-effectiveness of patient care. ECRI Institute PSO has experience analyzing over 1.6 million adverse events and near misses. ECRI Institute has a long history of investigating events and publishing authoritative risk reduction strategies. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority, winner of the 2006 John M. Eisenberg Award. For more information, visit Find ECRI Institute on Facebook ( and on Twitter (