A Near Miss, An Important Reminder


While the COVID-19 pandemic continues to pose a significant global health threat, one recent near-miss patient safety event at Brigham and Women’s Hospital was a reminder of the need for continued focus on all public health issues, transparency and our culture of safety.

According to the U.S. Department of Health and Human Services, over 130 individuals die daily from opioid-related drug overdoses across the country, with over 10.8 million Americans misusing prescription opioids in 2018.1 In 2017, the opioid crisis was declared a public health emergency and efforts have been ongoing to, among other things, reduce the number of opioid prescriptions written overall, as well as reduce the number of opioid pills ordered per prescription. Research shows that electronic medical records, computer systems used to manage patients’ information while at the hospital, may make the issue of overprescribing opioids worse by setting automatic suggestions for the number of pills doctors should prescribe following certain procedures.2

In June of this year, one of our General Surgery residents experienced this problem when ordering opioids for several of his patients in our electronic medical record system. When prescribing oxycodone, an opioid typically prescribed for severe pain management, like that experienced after surgery, the pre-populated quantity in the electronic medical record prescription suggested he order 450 pills, far more pills than necessary, rather than the five he originally intended to prescribe. Concerned that this suggestion would result in his patients receiving many more pills than they needed, and aware this can put patients at an increased risk for addiction, overdose and even death,3 he alerted the Information Technology, Pharmacy, and Patient Safety teams so they could work to eliminate this automatic suggestion. The teams worked quickly, and within 10 hours, the issue was fixed not only at our organization, but across all hospital systems that use the same technology.

We are grateful that we can consider this event a “near miss” in which no patients received more opioid pills than they needed. We are fortunate to have a culture of transparency in which this physician was willing to speak up about the patient safety issue he identified.


1U.S. Department of Health and Human Services. What is the Opioid Epidemic? https://www.hhs.gov/opioids/about-the-epidemic/index.html.

2Makary, MA., Overton, HN, Wang, P. Overprescribing is a Major Contributor to Opioid Crisis. BMJ. 2017 Oct 19. PMID: 29051174

3Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report.