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Joint Commission Issues New Sentinel Event Alert: Safe Use of Opioids in Hospitals

 (OAKBROOK TERRACE, Ill. – August 8, 2012) Although hospital patients may need the strong pain relief that only opioids can provide, a Sentinel Event Alert issued today by The Joint Commission urges hospitals to take specific steps to prevent serious complications or even deaths from opioid use.

Opioid analgesics rank among the drugs most frequently associated with adverse drug events. Research shows that opioids such as morphine, oxycodone and methadone can slow breathing to dangerous levels, as well as cause other problems such as dizziness, nausea and falls. The reasons for such adverse events include dosing errors, improper monitoring of patients and interactions with other drugs, according to The Joint Commission’s Sentinel Event Database. Reports also show that some patients, such as those who have sleep apnea, are obese or very ill, may be at higher risk for harm from opioids.

“Assessing and managing pain is critical to patients who otherwise would suffer, but avoiding the harm that accompanies the adverse effects of powerful opioid analgesics is equally important.  Hospitals should educate staff about the evidence-based actions recommended in this Alert,” says Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., president, The Joint Commission. “Accidental opioid overuse in the hospital is absolutely preventable. Information in this Alert will help doctors and nurses keep patients safe.”

The Joint Commission Alert recommends that health care organizations take the following actions:

  • Implement effective practices, such as monitoring patients who are receiving opioids on an ongoing basis, use pain management specialists or pharmacists to review pain management plans, and track opioid incidents.

  • Use available technology to improve prescribing safety of opioids such as creating alerts for dosing limits, using tall man lettering in electronic ordering systems, using a conversion support system to calculate correct dosages and using patient-controlled analgesia (PCA).

  • Provide education and training for clinicians, staff and patients about the safe use of opioids.

  • Use standardized tools to screen patients for risk factors such as oversedation and respiratory depression.

The Joint Commission Alert also includes details about respiratory depression risk factors and offers information relevant to opioid risks and safety. The Joint Commission sought input for the Alert from experts across the United States, including the Cancer Pain Program at Northwestern University’s Feinberg School of Medicine, the University of Wisconsin Hospital and Clinics, the Hackensack (N.J.) University Medical Center and the University Medical Center in Tucson, Arizona.

The warning about risks associated with opioids is part of a series of Alerts issued by The Joint Commission. Previous Alerts have addressed health care worker fatigue, diagnostic imaging risks, violence in health care facilities, maternal deaths, health care technology, anticoagulants, wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on The Joint Commission website at


Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission evaluates and accredits more than 19,000 health care organizations and programs in the United States, including more than 10,300 hospitals and home care organizations, and more than 6,500 other health care organizations that provide long term care, behavioral health care, laboratory and ambulatory care services. The Joint Commission currently certifies more than 2,000 disease-specific care programs, focused on the care of patients with chronic illnesses such as stroke, joint replacement, stroke rehabilitation, heart failure and many others. The Joint Commission also provides health care staffing services certification for more than 750 staffing offices. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at

border The Joint Commission


View and download the Sentinel Event Alert:
Safe Use of Opioids in Hospitals

Video: Dr. Ana Pujols McKee, discusses the Alert

About The Joint Commission

FDA “Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics

Print-friendly News Release PDF



Click to view or download images or bios of our experts.

Mark R. Chassin

Ana Pujols McKee

Elizabeth Eaken Zhani
Media Relations Manager
The Joint Commission

Bret Coons
Media Relations Specialist
The Joint Commission
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