Unintentional Overdose, Unintentional Death

1.    What is the link to Crisis Management?

As the story unfolds with the removal of Oxycontin and OxyNeo from the formulary, Physicians and Pharmacists are switching patients from these drugs to other opioids, which has led to the death of a man who was given the wrong dosage (an overdose) for his chronic pain. As a result of an earlier change that was made by different provinces, a potential crisis has risen as it is evident education is required on the proper dosing of these alternative opioids to Physicians and Pharmacists.

2.    What stage of Crisis Management does the system appear to be at?

The system seems to at the risk stage for the drug regulation board, Provincial Pharmacy Associations and Provincial Medical Associations. There has been one reported fatal death and it is clear physicians are not aware of the proper course of treatment for other opioids. Stricter regulations and more training is needed on common substitutes to ensure no further deaths occur leading this risk to then become a crisis in the health care system.

For the regional health folks in Northwestern Ontario, such as the Doctor, the Pharmacist and the family of this man who died, this is a crisis. Essentially, the Physician will need to file a report and take responsibility for the prescription he gave. The Ontario Medical Association will need to assist with any court rulings etc if the family is to sue the Physician.

3.    How well does the system appear to be handling the situation?

The system seems to be handling the situation well. The coroner has addressed and found the reason of death in a timely manner (which can be lengthy at times).  Further, Dr. Wilson has sent an advisory to both the Ontario Pharmacist Association and the College of Physicians and Surgeons to work together to determine the appropriate dosage.  Less than 1 percent of opioids are due to medical error and therefore the guidelines in place should be sufficient. Also, the article does outline and educate the public on why physicians have not had time to read such guidelines given the complexity of their schedule and therefore builds a story for the need for re-education.

4.    What level of crisis preparedness does the system appear to have?

The system is at a level 3 based on a 5-point scale since the information guidelines are available, however because they were too long, physicians were not reading them. Furthermore, these guidelines are not binding and therefore some physicians remain in the dark about the proper treatment. There currently are no penalties imposed so it is difficult to build Physician accountability into the system. As a result, more training is necessary and stricter mandatory guidelines need to be imposed.

5.    What personal reactions/feelings does the description trigger in you?

I was shocked it happened so quickly. I expected the system could not foresee that something like this would happen in my earlier post but I didn’t suspect that it would be a Physician dosing issue.  Physicians have a fiduciary responsibility to provide safe and quality care and therefore even though the guideline is long, they should be reviewing this to ensure that they are providing the best care. The system should also be able to build some accountability for Physicians to meet such regulations

6.    What advice would you offer to those involved?

I would continue to advise the provinces to work together and form a committee to address the re-education of Physicians and Pharmacists. Further, the system should build in an accountability framework for Physicians to read such guidelines. The Ontario Medical Association should provide an update and a statement on this to the public that they are ensuring the safety of patients. 


Article Source: 
http://www.theglobeandmail.com/life/health/new-health/health-news/fatal-overdose-sparks-warning-about-switch-from-oxycontin/article2359721/