Improvement Science Professional
Development Program
Tackling Opioid-related Harm
Ashika Maharaj/Gill Robb
Global Trigger Tool (GTT)
• Systematic methodology for quantifying
patient harm using a targeted chart review
process
• Adverse Drug Event Trigger Tool (ADE TT)
subset of GTT
• Developed by IHI 2003
Definition of Harm
• ‘Unintended physical injury resulting from
or contributed to by medical care that
requires additional monitoring, treatment
or hospitalisation or that results in death’
• Reference: White Paper: IHI Global Trigger
Tool for Measuring Adverse Events 2009
Harm Category
Background
 Revelations from 2011 ADE data:
• 30% of medication-harm related to Opioids
• 23% of this was Constipation
• Risk highest on surgical wards
 Forum to discuss findings (mid 2012)
 Retrospective detailed analysis of a surgical
ward requested
Pareto Chart of Harm 2011
New Data Collection Tool
Baseline Data
N = 131
Opioids = 114
Harms = 49
Results: Focusing on Constipation
131
Records
Reviewed
114
Patients
prescribed
opioids
14%
Nausea &
Vomiting
49
Opioid-related
Harm
12%
Oversedated
8%
Other
32/ 49 (65%)
Constipation
25/ 32 (78%)
on
Regular
opioids
22 /25 (88%)
Charted
laxatives
16/25 (64%) not
monitored
regularly
14/22 (63%)
‘Delayed
Charting
12/22 (55%)
Delayed
administration
Opioids implicated in Harm
Morphine
Oxycodone
Codeine
Tramadol
Other
Projects identified
Project A
Tackling high rate of opioid-related constipation
Project B
Tackling opioid-related oversedation
Aim (Project A)
To reduce Opioid related constipation on
Ward 10 (combined surgical ward) from
30% to 15% by 1 July 2013
Driver Diagram
13
Change Concepts & Ideas for PDSAs
Idea for Testing in a
PDSA
Theory and prediction about what will happen
when you test this idea
Regular Bowel charts for all
patients on opioids
Regular bowel monitoring will identify problems
early allowing for effective intervention earlier
PRN Laxatives charted in
conjunction with opioids
routinely
If bowel charts are working well then nurses will be
alerted to administer laxatives early
Regular Laxatives charted
in conjunction with opioids
routinely
Laxatives to be administered in conjunction with
opioids daily
Patient Leaflets
Leaflet informing patients of constipation as an
adverse effect of opioids and to let nurses know if
bowels have not moved as per normal.
Measures
Name of
Measure
Is this an Outcome,
Process or Balancing
Measure?
% Patient Harm from
constipation
Outcome
% Laxatives Charted
concurrently with opioids
Process
% Laxatives Administered on
time
Process
% Bowels Monitored Regularly
Process
% Patients who developed
diarrhoea
Balancing
% Patients who refused
Balancing
Next steps (Project A)
1.Team established
2.Phase 1: Bowel monitoring (implemented)
3.Phase 2: Charting and administration
4.Phase 3: Patient Experience
5.Retrospective analysis
Examples
89 year old patient was admitted due to R) femur
fracture following a fall. His bowels did not open for
seven days whilst on the ward secondary to regular
oxycodone, fentanyl, and morphine. He required
several interventions including laxatives and fleet
enema.
Examples
35 year old was admitted to orthopaedics after
developing lower back pain in medical ward.
Cause was not identified, however, patients
bowel had not moved for five days. She was on
regular morphine for pain. It was only after she
complained that laxatives and enemas were
offered and her bowels opened.
Examples
Other DHB(worst case scenario): Patient passed away
suddenly and unexpectedly shortly after admission to
the Surgical Unit. The cause of death was ascertained
by the coroner to be due to bowel ischaemia (from
constipation) and that morphine could not be excluded
as a contributing factor. Patient had also been on
clozapine.
NO CRAP!
40% of patients on opioids experience harm in the form
of constipation, nausea and vomiting or over sedation
Constipation is the most common harm
When is constipation harm??
When the bowels have not opened for 3 days, requiring
an intervention and / or increased length of stay
This has an impact on the patient experience of care 
and the hospital’s bottom line! $$
63% of patients charted laxatives have delayed charting
TO GET THE MAX
CHART THE LAX!
55% of patients charted laxatives have delayed
administration
NO DELAYS
PROMPTNESS PAYS
By Gill Robb