Objectives: This study examined the published literature on case reports of opioid-related problems to create a compendium that might lead to greater awareness and fewer such events.
Methods: PubMed, Ovid, and the Cumulative Index to Nursing and Allied Health Literature were searched for case reports. A problem was defined as a healthcare provider's or patient's administration of an opioid in an unintended manner resulting in harm.
Results: From more than 2200+ unique articles, 104 met the inclusion criteria. Fentanyl was most implicated. Problems included pump programming errors, patients' chewing transdermal patches, and pediatric overdosing with an oral droplet dispenser. Of 105 articles, 19 focused on patients with cancer and 86 on patients without cancer.
Conclusions: This compendium of opioid-related problems might generate further discussion about how best to reduce their number and morbidity.