-
psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - to
take oxycodone 40 mg ER three times daily (180 OME), according to
the discharge summary … – Ultimately, the oxycodone ER prescription was never filled.
9
Case Details (Encounter 3)
• … • After routine postoperative recovery, she was discharged on
oxycodone ER 80 mg three times daily … 30 mg 30 5 Pharmacy B
Jun 17 Oxycontin ER 80 mg 90 30 Pharmacy B
Case Details (Encounter 4)
• Four … -
Acetaminophen
10 mg-325 mg 56 14 Pharmacy A
Sep 28 Oxycodone 15 mg 30 5 Pharmacy B
Table 4.
-
psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - She received oxycodone at 180-240 OME during this hospital stay and was discharged with instructions … to take oxycodone 40 mg ER three times daily (180 OME), according to the discharge summary. … Ultimately, the oxycodone ER prescription was never filled. … 30 mg
30
5
Pharmacy B
Jun 17
Oxycontin ER
80 mg
90
30
Pharmacy B
Note … In the meantime, the patient’s opioid dose gap was “covered” with oxycodone/acetaminophen.
-
psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
CE/MOC
Overdose of Gabapentin and Oxycodone in a Patient … Similarly, oxycodone has partial renal clearance, and at least a 50-75% dose reduction is recommended … not recommended in patients with moderate to severe renal impairment or those on hemodialysis. 12
Oxycodone … Oxycodone is considered a second-line therapy compared with other opioids and may be used with caution … Consult pain specialist
No
Fentanyl
Consult pain specialist
No
Use with Caution
Oxycodone
-
psnet.ahrq.gov/web-mm/miscalculated-risk
December 03, 2008 - [OxyContin], extended-release morphine [Avinza, Kadian], and methadone) are generally reserved for use … Using the Table , 10 mg of IV morphine is roughly equivalent to 20 mg of oral oxycodone. … Immediate-release oxycodone is dosed every 2 to 4 hours. … At the full conversion rate, two options for dosing are 9 mg of oxycodone every 2 hours or 18 mg of oxycodone … hydrochloride NA 20 2-4 *Values reflect immediate-release products.
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - in the past.
4
Case: Multifactorial Medication Mishap (2)
When the physician searched for liquid oxycodone … In all, the physician saw eight different choices for oxycodone products. … The physician chose the concentrated oxycodone liquid product and ordered a 5 mg dose.
5
Case: Multifactorial … providers lacked pertinent drug information to make safe decisions
Physician was unaware that liquid oxycodone … A few key factors include:
Absence of prescribing criteria for and restriction of oxycodone
Lack of standard
-
psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - When the physician searched for liquid oxycodone in the computerized prescriber order entry (CPOE) system … In all, the physician saw eight different choices for oxycodone products. … The physician chose the concentrated oxycodone liquid product, and ordered a 5-mg dose. … The list of choices that resulted when oxycodone was searched in the CPOE system was confusing. … Even though there were four distinct oxycodone products, eight were listed due to duplication.
-
psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 20, 2024 - On these days, she was also given oxycodone, which was highly effective and allowed her to rest the whole … He discovered the patient had received oxycodone 3 times in less than 8 hours (1 dose prior to the dressing … The nurse checked the automated dispensing machine in which the oxycodone was stored and was surprised … to find a higher concentration of oxycodone solution stored in place of the typical, lower concentration … Root cause analysis (RCA) by the safety committee determined the higher concentration of oxycodone solution
-
psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - The surgeon prescribed oxycodone. … At the time of hospital admission, the patient did not remember to mention the oxycodone as a new medication … Unaware that the patient had started taking oxycodone, the anesthesiologist, hoping to achieve adequate … in the postanesthesia care unit, the patient became somnolent from receiving morphine on top of the oxycodone … If the inpatient medical record had been automatically updated to include the patient's oxycodone, the
-
psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone … changes to reduce adverse events from drug-
disease interactions
3
OVERDOSE OF GABAPENTIN AND
OXYCODONE … Similarly, oxycodone has partial renal clearance, and at least a 50-75% dose
reduction is recommended … d
No
Methadone Consult pain specialist No
Fentanyl Consult pain specialist No
Use with Caution Oxycodone … • Oxycodone is considered a second-line therapy compared with other
opioids and may be used with
-
psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
October 01, 2009 - His primary care physician (PCP) had been prescribing high doses of long-acting morphine (MS Contin), oxycodone … 45 days.( 1,2 ) Furthermore, US patients consume an incredible 99% of all hydrocodone and 83% of all oxycodone … The morphine and oxycodone were discontinued. … In reviewing his medications, the patient had refilled his long-acting morphine and oxycodone 1 day before … It would have been safer to manage with short-acting oxycodone.
-
psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - PO: 30-60 min
IV: 15-30 min
PO: ~60 min
Immediate release (IV, PO): 3-6 h
Oxycodone … Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone … Oxycodone. In: StatPearls . … March 1, 2023
WebM&M Cases
Overdose of Gabapentin and Oxycodone
-
psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Morphine IV: 5-10 min
PO: 30-60 min
IV: 15-30 min
PO: ~60 min
Immediate release (IV,
PO): 3-6 h
Oxycodone … Prescribing of opioid analgesics and related mortality before and after the introduction of long-
acting oxycodone … Oxycodone. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021.
-
psnet.ahrq.gov/issue/how-maximize-patient-safety-when-prescribing-opioids
March 18, 2015 - August 16, 2023
WebM&M Cases
Overdose of Gabapentin and Oxycodone
-
psnet.ahrq.gov/issue/quality-connection
November 25, 2020 - 2023
WebM&M Cases
Overdose of Gabapentin and Oxycodone
-
psnet.ahrq.gov/issue/computerized-order-entry-limited-decision-support-prevent-prescription-errors-picu
January 31, 2018 - 2023
WebM&M Cases
Overdose of Gabapentin and Oxycodone
-
psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - The increase appeared to be driven largely by the introduction of oxycodone onto our provincial formulary … the mid to late 1990s, it became quite common for people to take even stronger opioids, specifically oxycodone … We've all seen patients who take oxycodone or some other opioid and in the short term feel a whole lot … in the US in 2013 alone, enough for every adult in the country to get a 4-week continuous supply of oxycodone
-
psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - His home
medications included lisinopril, metoprolol, colchicine, sertraline,
acetaminophen and oxycodone
-
psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - in the US in 2013 alone, enough for every adult in the country to get a 4-week continuous supply of oxycodone … The increase appeared to be driven largely by the introduction of oxycodone onto our provincial formulary … the mid to late 1990s, it became quite common for people to take even stronger opioids, specifically oxycodone … We've all seen patients who take oxycodone or some other opioid and in the short term feel a whole lot
-
psnet.ahrq.gov/primer/clinical-decision-support-systems
September 07, 2019 - 2023
WebM&M Cases
Overdose of Gabapentin and Oxycodone
-
psnet.ahrq.gov/issue/prescription-errors-related-use-computerized-provider-order-entry-system-pediatric-patients
November 07, 2018 - 2023
WebM&M Cases
Overdose of Gabapentin and Oxycodone