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Root Cause Analysis Paper - Overuse of Pain Medication in the ER

Morgan Butler

Bon Secours Memorial College of Nursing

NUR 3206

Cynthia Woods
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Difficulty with reviewing

Poor DocumentationPMH
-Nursing cannot
-Lack of notes r/t access all MD notes
“seeking,” behavior & medical history
-Non-Uniform with ease. Overuse and/or over
“flagging,” of medical
Lack of accountability
records Fear of bad prescribing of narcotic
for prescribing patient pain medications in
narcotics satisfaction scores the ER
-Everyone talks about -MD’s prescribe/order
the issue but nothing meds based on pt
seems to happen... requests d/t fear of
complaints.
Fishbone
Diagram

In the ER, pain management is a common struggle. Patient care includes the assessment
of pain, and it is very important to manage pain. This can sometimes be “tricky,” in the ER, as
sometimes the health care services that are offered are abused. This can lead to overuse of pain
medication. There are several factors related to this issue, as seen in the above diagram. These
factors are a mix of many different things, including the following: fear of patient complaints
and/or lesser satisfaction scores, inconsistent or poor documentation, lack of accountability for
over-ordering or over-prescribing, and difficulty with reviewing PMH.

The AHC Media notes that, “a drug seeker is defined as a patient who requests the
prescription of a legal drug for resale, personal use, and/or family use. Generally, these are non-
medical uses of the prescription drug, which refers to a use pattern that exceeds the
recommended dose in amount or frequency,” (Velez, 2004). It is not uncommon to see or hear
that a patient has made multiple trips to several different ER’s because they want more pain
medication...sometimes even multiple trips in one day. The patient’s behavior can sometimes
turn violent, and patients present with “multiple alleged allergies to narcotics who are asking for
a medication that the physician never would have initially thought of prescribing, whose
medications were stolen, and who become angry, threatening, and agitated upon refusal to refill
the stolen prescription,” (Velez, 2004). This can be intimidating for ER staff and providers.

It has been noted that when patient satisfaction scores are posted on the internet,
physicians' reputations are affected (Bachman, 2016). This leads to fear of “bad,” scores or
patient complaints. The US National Library of Medicine notes that some providers, “find it too
difficult to refuse requests for drugs of dependence,” (James, 2016). At times, patients that are
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demanding or threatening can lead to overuse and/or overprescribing of narcotic pain

medications. This is due to the fears aforementioned, and often times to keep patients “quiet and
happy.” The rushed pace of the ER at times also may be a factor that contributes to these issues.

The Virginia Department of Health notes that, “The prescription monitoring program
collects prescription data for Schedule II-IV drugs into a central database which can then be used
by limited authorized users to assist in deterring the illegitimate use of prescription drugs.” This
is great - as long as it is consistently used. Some facilities have “flags,” for patient charts but it
seems to be inconsistent and depends on the provider. This makes it difficult to track overuse and
overprescribing of narcotics. There are tools in place, they just need to be consistently and
constantly used. Failure to use the tools or acknowledge “flags,” on patient’s charts are often
ignored. Nurses often do not have access to some of this information.

Some problems that Physicians may demonstrate related to overprescribing of narcotics

can include the following, per the American Medical Association: dated, duped, dishonest, and
disabled. These things can be related to why there are inconsistencies in the use of narcotics in
the ER - if a physician is “dated,” or not up-to-date on current knowledge it can cause problems.
If a physician is “duped,” by a drug-seeking patient because they truly believe their complaints
of pain, then they are prolonging the issues. If a physician is “dishonest,” they may write
prescriptions for some kind of personal gain, but this is, “thankfully, uncommon,” (Longo,
2000). Lastly, if a physician has issues such as medical or psychiatric disabilities, they, may be
“loose” prescribers of controlled substances and may be less likely to confront patients who are
abusing substances out of fear of turning suspicion on themselves,” (Longo, 2000).

Overall, there are many factors that may contribute to the issue of overuse and/or
overprescribing narcotic pain medications in the ER. The issue is an ongoing battle, and
hopefully more standardized practices will come into practice to ensure that this isn’t an issue.
The flagging of patient’s charts and standard policies need to be consistent, and the use of
monitoring programs should also be consistent. Failure to follow the strict guidelines, perhaps in
the future, may require some additional training and/or education. The issue of overuse and/or
overprescribing narcotic pain medication in any setting can be dangerous, and great care should
be taken related to this.

References:
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Bachman M.D, J. (2016) The Problem with Patient Satisfaction Scores. American
Academy of Family Physicians. AAFP. Web. Retrieved from:
http://www.aafp.org/fpm/2016/0100/p23.html

James, J. (2016) Dealing with Drug-Seeking Behavior. Us National Library of Medicine:

National Institutes of Health. Web. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919169/

Longo, M.D, L. (2000) Addiction: Part II. Identification and Management of the
Drug-Seeking Patient. American Academy of Family Physicians. AAFP. Web. Retrieved
from: http://www.aafp.org/afp/2000/0415/p2401.html

Velez M.D, L. (2004) Dealing with Drug-Seeking Patients in the Emergency

Department. AHC Media: A Relias Learning Company. Web. Retrieved from:
https://www.ahcmedia.com/articles/7558-dealing-with-drug-seeking-patients-in-the-emergency-
department

Virginia Department of Health Professions (2017) Virginia Prescription Monitoring

Program: Description of Program. Virginia.Gov. Web. Retrieved from:
https://www.dhp.virginia.gov/dhp_programs/pmp/pmp_desc.asp