Table 3

Solutions Implemented, by Deficiencya

Deficiency AddressedSolution(s) Implemented
Inconsistent sedation assessments of patients receiving opioids: different scales in use, no uniform practice on frequency of assessment or action steps to be taken, hospital policies did not adequately address the optimum scale or the frequency of monitoring to be done• POSS introduced after trial on the joint and spine unit; rolled out to all adult care units as the standard evidence-based assessment tool
• Hospital policies on pain management revised to include use of POSS and standardize frequency of assessment
Poor communication among team members regarding level of sedation• Implemented new report within EMR to show pain scores, sedation score, medications given, and vital signs in a single location
• Introduced discussion of sedation score to the content of daily interprofessional rounds and bedside shift report
Clinical culture stressed the elimination of pain and/or the achievement of a pain score below an arbitrary number• Reeducated staff and rewrote hospital policies, indicating that goals of pain management should be individualized
Knowledge deficits among prescribers in the following areas: opioid conversions, patient-level risk factors, other sedating medications, risk of long-acting medications, danger of rapid escalation, incomplete cross-tolerance• Education delivered to hospitalists tailored to deficits identified by opioid knowledge assessment
• EMR live link to opioid conversion table from the opioid order page
• Clinical decision support/best-practice alert to fire when initiating opioids in patients with comorbid conditions or taking other sedating medications; advisory recommends lower starting doses and sedation monitoring
• Computerized decision support defaults to lower-dose opioid drip for high-risk patients based on computer detection of patient factors identified in chart
Underappreciation of high incidence of OSRD with hydromorphone (used frequently in ED and then converted to infusions on floors)• Reduced ED hydromorphone use by creating new pain order sets with default to morphine
• Added morphine 4 mg to automated drug-dispensing cabinet instead of hydromorphone
Underappreciation of risks of long-acting opioids in opioid-naive patients; misunderstanding of definition of opioid naive• Removed long-acting opioids from preoperative orthopedic order set
• Best-practice alert that defines opioid naive when ordering long-acting opioids
  • a POSS = Pasero Opioid Sedation Scale, EMR = electronic medical record, OSRD = oversedation and respiratory depression, ED = emergency department.