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  • Writer's pictureThe Communiqués

Future Leaders Communiqué Volume 6 Issue 3 July 2021

Download PDF: FL Communiqué July 2021

  • Guest Editorial

  • Editorial

  • Case: When more is not better

  • Expert Commentary: Time to extend our medication safety net

  • Expert Commentary: Don't give more if it makes them snore

  • Comments From Our Peers


Welcome to the July 2021 edition of the Future Leaders Communiqué. In this edition, we examine two topics central to patient safety: iatrogenic injury, and barriers to escalation of care. Our case is that of Mr A, a 53 year old man admitted to hospital with severe neck pain who was found dead in his hospital bed three days later. The coroner found that this was a preventable death as it was due to fentanyl and oxycodone toxicity.

Every day in Australia, on average, three people die from opioid toxicity.¹ In this cohort, pharmaceutical opioids are responsible for more deaths than heroin. Despite this, the prescription of pharmaceutical opioids continues to increase in Australia.² In 2017, one in eight Australians had one or more opioid prescriptions dispensed.¹ The reasons for this increase are multifactorial, but it is abundantly clear that mitigation of harm must become our highest priority whenever we consider the prescription of opioids to our patients. To that end, both expert commentaries for this edition offer insights and advice on the safe prescription and monitoring of opioid medications. We hope you find their pearls of wisdom helpful in navigating this challenging area of clinical practice.

Throughout the course of Mr A’s hospital admission there were several clinical reviews which, by the standard of local protocol, should have triggered an escalation in his clinical care. Testimony from those involved in Mr A’s care revealed that the reasons escalations did not occur included staff inexperience with opioid toxicity and not wishing to inconvenience colleagues. There is a dissonance in this reasoning that is worth further reflection.

Protocols for clinical escalation are familiar to most if not all health professionals. The purpose of these protocols are to trigger an automatic clinical escalation and, to remove variations in care that may occur due to inexperience or cultural influences. It appears that in the tragic case of Mr A, these more human factors trumped the automatic escalation protocols. This is perhaps unsurprising, but it reminds us that the workplace culture, to which we contribute to in our day-to-day practice, may have a profound impact on patient care. It is not enough to simply remove barriers to escalation. We must work to create a psychologically safe environment in which even the most junior staff feel comfortable to raise their concerns. We should encourage questions and promote discussions amongst our teams so that each team member has a shared understanding of any given scenario. When errors, oversights or near-misses occur, we must embrace these as opportunities to understand where care could be improved. All of this is far easier said than done. It requires insight, a sustained focus on and how we contribute to our workplace culture. Our patients deserve nothing less.

Our guest editor for this edition is Dr Kate Charters. Dr Charters is an Emergency Registrar with a passion for evidence-based medicine and a particular interest in public health. She is currently working as an Emergency Registrar at Alfred Health, Melbourne, and is an advanced trainee with the Australasian College for Emergency Medicine (ACEM). Kate has navigated the labyrinthine details of this coroner’s report to bring sharp focus to the learning points from the case and engaged two exemplary clinicians and educators - Dr Anna Korin and Anne Leversha - to explore and unpack these topics further.

We very much hope this edition adds to your understanding of opioid toxicity and barriers to escalation of care. It serves as a resource for reflecting on and evolving your clinical practice. On a final note, remember each edition of the Future Leaders Communiqué is available as a podcast with additional interview material from our guest authors – find out more on our website ( or subscribe via iTunes, Stitcher, or Spotify.


Australian Institute of Health and Welfare 2018, Opioid harm in Australia: and comparisons between Australia and Canada, AIHW, Canberra

Australian Institute of Health and Welfare (AIHW) 2021, Alcohol, tobacco & other drugs in Australia


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