Concerns Related to an Inpatient’s Response to Oxycodone and Facility Actions at the Baltimore VA Medical Center, Maryland

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to a patient’s response to oxycodone, an opioid pain mediation, including initial post-surgery care and during an acute change in condition (event) at the facility. The OIG also assessed management actions taken by the facility after the event. The OIG found that although providers ordered and nursing staff administered oxycodone consistent with manufacturer’s recommendations, the patient developed signs and symptoms of altered mental status, slowed breathing, and low oxygen in the tissues. The patient was administered naloxone and the symptoms immediately improved. Naloxone has no effect as an antidote in reversing adverse drug event symptoms when given to patients who have not taken opiates. Naloxone’s effectiveness in treating the signs and symptoms supports that the patient was having a response to oxycodone. Providers assessed and treated the patient’s adverse drug event symptoms and the patient did not have further episodes. Facility managers did not consider the patient’s response to oxycodone as one that required a review to determine causative factors and did not report the event to the Veterans Health Administration Adverse Drug Event program or conduct a root cause analysis or an aggregate review. These reviews would have allowed for communication between facility staff and leaders, and patient safety improvement considerations regarding the oxycodone vulnerabilities. The OIG found a clinical disclosure, though warranted, was not documented. An institutional disclosure was conducted approximately six weeks after the event. The Director did not ensure compliance with facility’s peer review policy. In addition, the Surgical Work Group did not meet monthly and meeting minutes lacked discussion of required data. The OIG made six recommendations related to resident supervision; reviewing, capturing and reporting adverse drug events; peer reviews; and documentation of clinical disclosures, and Surgical Work Group meetings.