Threats to Narcotic Safety—A Narrative Review of Narcotic Incidents, Discrepancies and Near-Misses Within a Large Canadian Health System

BACKGROUND: Canada is currently experiencing an opioid crisis. PURPOSE: Nurses are the largest number of frontline healthcare professionals in Canada who administer narcotic pharmacotherapy, hence, they are ideally placed to improve narcotic stewardship in hospitals. Our study aims to understand the characteristics of narcotic incidents and hence recommend interventions for narcotic stewardship. METHODS: Our study was conducted within a 442-bed academic health sciences center in Ontario. We extracted anonymized narcotic incident reports which occurred over a 3-year period from the SAFER System. Descriptive statistics were utilized to analyze narcotic incidents and their contributory factors. RESULTS: 272 narcotic incident reports were submitted to SAFER within the study period. Most incidents (51%) involved hydromorphone and morphine and were primarily categorized as Level I (n = 154) and Level II (n = 60). Incorrect narcotic dosing (44%), and narcotic count discrepancies (27%) were most commonly reported with active failures being the most commonly reported contributory factors such as failure to review medication orders prior to narcotic administration. CONCLUSIONS: Nurses have an important role in narcotic safety as an intermediary between narcotic administration and incident reporting. Further research is needed to understand the enablers, barriers and opportunities for nurses and other healthcare professionals to improve narcotic stewardship.