{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:43:42Z","timestamp":1760165022979,"version":"build-2065373602"},"reference-count":21,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2021,5,7]],"date-time":"2021-05-07T00:00:00Z","timestamp":1620345600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pharmacy"],"abstract":"<jats:p>Although opioids are the cornerstone of moderate-to-severe acute pain management they are appropriately recognised as high-risk medicines. Patient and health service delivery factors can contribute to an increased risk of death associated with excessive sedation and respiratory impairment. Despite increasing awareness of opioid-induced ventilation impairment (OIVI), no reliable method consistently identifies individual characteristics and factors that increase mortality risk due to respiratory depression events. This study assessed similarities in available coronial inquest cases reviewing opioid-related deaths in Australian hospitals from 2010 to 2020. Cases included for review were in-hospital deaths that identified patient factors, clinical errors and service delivery factors that resulted in opioid therapy contributing to the death. Of the 2879 coroner\u2019s inquest reports reviewed across six Australian states, 15 met the criteria for inclusion. Coroner\u2019s inquest reports were analysed qualitatively to identify common themes, contributing patient and service delivery factors and recommendations. Descriptive statistics were used to summarise shared features between cases. All cases included had at least one, but often more, service delivery factors contributing to the death, including insufficient observations, prescribing\/administration error, poor escalation and reduced communication. Wider awareness of the individual characteristics that pose increased risk of OIVI, greater uptake of formal, evidence-based pain management guidelines and improved documentation and observations may reduce OIVI mortality rates.<\/jats:p>","DOI":"10.3390\/pharmacy9020101","type":"journal-article","created":{"date-parts":[[2021,5,7]],"date-time":"2021-05-07T22:36:24Z","timestamp":1620426984000},"page":"101","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Opioid-Induced In-Hospital Deaths: A 10-Year Review of Australian Coroners\u2019 Cases Exploring Similarities and Lessons Learnt"],"prefix":"10.3390","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9643-0096","authenticated-orcid":false,"given":"Nicholas","family":"Smoker","sequence":"first","affiliation":[{"name":"College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ben","family":"Kirsopp","sequence":"additional","affiliation":[{"name":"Southern Adelaide Local Health Network, Bedford Park, SA 5042, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4786-022X","authenticated-orcid":false,"given":"Jacinta Lee","family":"Johnson","sequence":"additional","affiliation":[{"name":"UniSA Clinical &amp; Health Sciences, University of South Australia, Adelaide, SA 5001, Australia"},{"name":"SA Pharmacy, SA Health, Adelaide, SA 5001, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,5,7]]},"reference":[{"key":"ref_1","first-page":"59","article-title":"We should focus on \u201cwhen\u201d as well as \u201cwhom\u201d to monitor for postoperative opioid-induced ventilatory impairment","volume":"31","author":"Lorri","year":"2018","journal-title":"APSF Newslett."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"317","DOI":"10.2217\/pmt.14.19","article-title":"Opioid-induced respiratory depression in the acute care setting: A compendium of case reports","volume":"4","author":"Overdyk","year":"2014","journal-title":"Pain Manag."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"S27","DOI":"10.1097\/01.NAJ.0000513528.79557.33","article-title":"Monitoring hospitalized adult patients for opioid-induced sedation and respiratory depression","volume":"117","author":"Jungquist","year":"2017","journal-title":"Am. 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