Root Cause Analysis of Adverse Events Involving Opioid Overdoses in the Veterans Health Administration



      The Veterans Health Administration (VHA) serves a population with compounding risk factors for opioid misuse, including chronic pain, substance use disorders, and mental health conditions. The objective of this study was to analyze opioid-related adverse events and root causes to inform mitigation strategies associated with opioid prescribing and administration.


      The researchers conducted a retrospective analysis of root cause analysis reports of opioid overdose events between August 1, 2012, and September 30, 2019. These adverse events were investigated locally by multidisciplinary hospital teams and reported by VHA facility patient safety managers to the National Center for Patient Safety for further aggregation and analysis. Type of event, location, and root causes were categorized.


      Eighty-two adverse event reports were identified. Patients were primarily male with an average age of 61.4 years. Staff medication administration errors were the most common event type (57.3%), with most events resulting from process errors (65.9%) occurring in the health care setting (85.4%). Overall 36 events (43.9%) resulted in major or catastrophic harm. There were 172 root causes identified. The most common root causes were staff not following existing policy or lack of existing hospital policy on opioid management (18.0%); staff lacked training in areas such as managing the use or administration of opioids, correct use of opioid dispensing equipment, and recognition and proper response to an overdose (12.2%); and poor communication of opioid prescribing or administration during handoffs between clinical teams (11.6%). A lack of standardization in processes, training, and policies on opioid prescribing and screening, medication administration, equipment/pumps purchase and use, and contraband searches was a common theme throughout.


      Errors in prescribing and administration of opioid medication can result in significant harm. A lack of standardized opioid administration practices and training, controlled substance policies, and interdisciplinary communication were frequent factors in adverse opioid events and should be a focus for future prevention.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Joint Commission Journal on Quality and Patient Safety
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Scholl L
        • et al.
        Drug and opioid-involved overdose deaths—United States, 2013–2017.
        MMWR Morb Mortal Wkly Rep. 2018 Jan 4; 67: 1419-1427
        • Mattson CL
        • et al.
        Opportunities to prevent overdose deaths involving prescription and illicit opioids, 11 states, July 2016–June 2017.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 31; 67: 945-951
        • Kandel DB
        • et al.
        Increases from 2002 to 2015 in prescription opioid overdose deaths in combination with other substances.
        Drug Alcohol Depend. 2017 Sep 1; 178: 501-511
      1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Data Overview: The Drug Overdose Epidemic: Behind the Numbers. Mar 25, 2021. Accessed 7 May 2021.

        • Wilson N
        • et al.
        Drug and opioid-involved overdose deaths—United States, 2017–2018.
        MMWR Morb Mortal Wkly Rep. 2020 Mar 20; 69: 290-297
        • Lin LA
        • et al.
        Changing trends in opioid overdose deaths and prescription opioid receipt among veterans.
        Am J Prev Med. 2019; 57: 106-110
        • Nadpara PA
        • et al.
        Risk factors for serious prescription opioid-induced respiratory depression or overdose: comparison of commercially insured and Veterans Health Affairs populations.
        Pain Med. 2018 Jan 1; 19: 79-96
        • Oliva EM
        • et al.
        Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.
        Psychol Serv. 2017; 14: 34-49
        • Webster LR.
        Risk factors for opioid-use disorder and overdose.
        Anesth Analg. 2017; 125: 1741-1748
        • Bohnert ASB
        • Ilgen MA.
        Understanding links among opioid use, overdose, and suicide.
        N Engl J Med. 2019 Jan 3; 380: 71-79
        • US Department of Veterans Affairs
        Office of Mental Health and Suicide Prevention. 2020 National Veteran Suicide Prevention Annual Report..
        Nov 2020
        • Baser O
        • et al.
        Prevalence of diagnosed opioid abuse and its economic burden in the Veterans Health Administration.
        Pain Pract. 2014; 14: 437-445
        • Seal KH
        • et al.
        Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan.
        JAMA. 2012 Mar 7; 307: 940-947
        • Makary MA
        • Daniel M.
        Medical error—the third leading cause of death in the US.
        BMJ. 2016 May 3; 353: i2139
      2. World Health Organization. Patient Safety. Sep 13, 2019. Accessed 7 May 2021.

        • Brennan TA
        • et al.
        Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991.
        Qual Saf Health Care. 2004; 13: 145-151
        • Thomas EJ
        • et al.
        Incidence and types of adverse events and negligent care in Utah and Colorado.
        Med Care. 2000; 38: 261-271
        • Simas da Rocha B
        • et al.
        Interventions to reduce problems related to the readability and comprehensibility of drug packages and labels: a systematic review.
        J Patient Saf. Epub. 2020 Apr 3;
        • Bagian JP
        • et al.
        Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about.
        Jt Comm J Qual Improv. 2001; 27: 522-532
        • Weeks WB
        • Bagian JP.
        Developing a culture of safety in the Veterans Health Administration.
        Eff Clin Pract. 2000; 3: 270-276
        • US Department of Veterans Affairs
        Veterans Health Administration. VHA National Patient Safety Improvement Handbook.
        VHA Handbook, Mar 4, 2011 (1050.01)
        • Beaudoin FL
        • et al.
        Preventing iatrogenic overdose: a review of in-emergency department opioid-related adverse drug events and medication errors.
        Ann Emerg Med. 2015; 65: 423-431
        • Kumar S
        • Steinebach M.
        Eliminating US hospital medical errors.
        Int J Health Care Qual Assur. 2008; 21: 444-471
        • Barnett ML
        • et al.
        Emergency physician opioid prescribing and risk of long-term use in the Veterans Health Administration: an observational analysis.
        J Gen Intern Med. 2019; 34: 1522-1529
        • Hill MV
        • et al.
        Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.
        Ann Surg. 2017; 265: 709-714
        • Schifano F
        • et al.
        Assessing the 2004–2018 fentanyl misusing issues reported to an international range of adverse reporting systems.
        Front Pharmacol. 2019 Feb 1; 10: 46
        • Geile J
        • et al.
        Fatal misuse of transdermal fentanyl patches.
        Forensic Sci Int. 2019; 302109858
        • Oliva EM
        • et al.
        Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation.
        BMJ. 2020 Mar 4; 368 (m283)
        • Lin LA
        • et al.
        Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans.
        Pain. 2017; 158: 833-839
        • Im JJ
        • et al.
        Association of care practices with suicide attempts in US veterans prescribed opioid medications for chronic pain management.
        J Gen Intern Med. 2015; 30: 979-991