Should mismanaged pain be considered an adverse event?


This week’s EBN Twitter Chat on Wednesday 18th March between 8-9 pm (UK time) will focus on whether mismanaged (undertreated) pain should be considered an adverse event. The Twitter Chat will be hosted by Dr Alison Twycross (@alitwy) who is editor of EBN and has also done lots of work in the area of paediatric pain management. This Blog provides some context for the Chat. The examples given relate to paediatric pain but the principles apply to pain in patients of all ages.

Participating in the Twitter Chat

Participating in the twitter chat requires a Twitter account; if you do not already have one you can create an account at Once you have an account contributing is straightforward, You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

Mismanaged pain as an adverse event

An adverse event has been defined as:

An injury related to medical management, in contrast to complications of disease. Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse events may be preventable or non-preventable.”[1]

The idea of mismanaged (undertreated) pain being treated as an adverse event was first raised around five years ago [2]. Chorney et al. argue that medically caused pain (post-operative and procedural) is health care professionals’ dirty little secret.

If we consider the case of paediatric procedural and post-operative pain management practices the knowledge to guide practice is readily available [3] but many children continue to experience moderate to severe unrelieved pain during hospitalization [4, 5]. However, at the moment if health care professionals do not manage patients’ pain adequately there is no come back on them. In addition there appears to be a general acceptance among professionals and patients that just because a person is in hospital for surgery or a procedure that they can expect to be in moderate to severe pain for at least some of the time with little acknowledgment of the consequences of unrelieved pain (see below).

Mismanaged (undertreated) acute pain following surgery or procedures fits the definition of an adverse event for several reasons. First, this pain is a direct result of medical management. Pain in hospital results from a range of procedures, for example, venepunctures, chest tubes, and surgery. Without adequate treatment, the pain from these procedures is often severe and above the threshold which parents and children find acceptable [6, 7], with 33-82% of children experiencing moderate to severe pain during hospitalization [8, 9]. Second, pain can have detrimental consequences for children. Early experiences with pain, have been associated with a range of adverse behavioural and physiological consequences [10, 11]. Regardless of age, pain and associated tissue injury cause a cascade of hormonal, neuro-chemical, and electro-physiological responses that impact on physical outcomes such as wound healing, cardiac ischemia, and immobilization [12]. Mismanaged acute pain can also lead to chronic post-operative pain in adults [13] and children [14],

The definition of an adverse event provided earlier makes it clear that failure to diagnose or treat should be considered an adverse event [1]. Given this, it could be argued that the following should be considered adverse events:

  • Not assessing or reassessing pain
  • Not administering or prescribing sufficient analgesic drugs post-operatively or prior to a painful procedure
  • Not using non-drug methods to help manage post-operative or procedural pain

There will be other examples you will be able to come up. Attempts have been made to identify adverse event indicators for paediatric post-operative and procedural pain [15] but these have proved difficult to implement in practice.

During the Twitter Chat we will discuss, among other things:

  1. Whether mismanaged pain should be treated as an adverse event.
  2. Whether treating mismanaged pain as an adverse event would help change practices and reduce the amount of pain patients experience.
  3. What pain-related events should be considered adverse events.
  4. Would having to invoke a hospital’s adverse event procedure if a patient experienced mismanaged pain encourage health care professionals to manage pain more effectively?
  5. When does acute pain become mismanaged/undertreated? Can we identify a point on a scale of 0-10?

Alison Twycross

Head of Department for Children’s Nursing and Reader in Children’s Pain Management

Department of Children’s Nursing, School of Health and Social Care

London South Bank University


  1. World Health Organisation, WHO Draft Guidelines for Adverse Event Reporting and Learning Systems: From Information to Action. 2005, WHO: Geneva.
  2. Chorney, J.M., P.J. McGrath, and G.A. Finley, Pain as the neglected adverse event. Canadian Medical Association Journal, 2010. 182(7): p. 732.
  3. Association of Paediatric Anaesthetists, Good Practice in Postoperative and Procedural Pain Management, 2nd edition. Pediatric Anesthesia, 2012. 22(S1): p. 1-79.
  4. Birnie, K.A., et al., Hospitalized children continue to report undertreated and preventable pain. Pain Research and Management, 2014. 19(4): p. 198-204.
  5. Twycross, A. and G.A. Finley, Children’s and parents’ perceptions of postoperative pain management: A mixed methods study. Journal of Clinical Nursing, 2013. 22(21-22): p. 3095–3108.
  6. Gauthier, J.C., G.A. Finley, and P.J. McGrath, Children’s self-report of postoperative pain intensity and treatment: threshold: determining the adequacy of medication. Clinical Journal of Pain, 1998. 14(2): p. 116-120.
  7. Birnie, K.A., C.T. Chambers, and P.J. McGrath, When does pain matter? acknowledging the subjectivity of clinical signficance. Pain, 2012. 153(12): p. 2311-2314.
  8. Stevens, B.J., et al., Pain assessment and intensity in hospitalized children in Canada. The Journal of Pain, 2012. 13(9): p. 857-865.
  9. Twycross, A. and S. Collis, How Well Is Acute Pain In Children Managed? A Snapshot In One English Hospital. Pain Management Nursing, 2013. 14(4): p. e204-e215.
  10. Taddio, A. and J. Katz, The effects of early pain experience in neonates on pain responses in infancy and childhood. Pediatric Drugs, 2005. 7(4): p. 245-257.
  11. Anand, K.J.S., et al., Analgesia and sedation in preterm neonates who require ventilatory support: results from the NOPAIN trial. Archives of Pediatric Adolescent Medicine, 1999. 153(4): p. 331-338.
  12. Carr, D.B. and L.C. Goudas, . Acute pain. LANCET, 1999: p. 2051-2058.
  13. Kehlet , H., T.S. Jensen, and C.J. Woolf, Persistent postsurgical pain: risk factors and prevention. Lancet, 2006. 367: p. 1618-1625.
  14. Fortier, M.A., et al., Acute to chronic postoperative pain in children: Preliminary findings. Journal of Pediatric Surgery, 2011. 46(9): p. 1700-1705.
  15. Twycross, A., et al., A Delphi Study to Identify Adverse Event Indicators for Pediatric Post-operative and Procedural Pain. Pain Research and Management, 2013. 18(5): p. e68-e74.

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