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Comprehensive Program That Includes Standardized Protocols and Pain Management Team Significantly Reduces Narcotic Oversedation in Hospital Setting

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Fairview Southdale Hospital (FSH) developed a comprehensive program to reduce the oversedation of patients with narcotic medications. Inspired by the establishment of an aggressive goal, FSH developed a program consisting of standardized protocols; a patient management team to support adherence to the protocols; revised processes in the operating rooms (ORs), recovery rooms, and postoperative floors; and pharmacist support. The program resulted in an 81 percent decline in the rate of serious narcotic oversedation between 2003 and 2006; based on this success, the program is now being expanded to hospitals throughout the Fairview Health Services system.

Evidence Rating (What is this?)

Moderate: This evidence consists of pre- and post-implementation comparisons of narcotic oversedation.
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Developing Organizations

Fairview Health Services
Fairview Health Services is located in Minneapolis, MN.end do

Use By Other Organizations

FSH initiatives to monitor oversedation are being spread throughout the Fairview Health System, with a system-wide pain committee working to adapt many of these changes to other hospitals within the system.

Date First Implemented


Problem Addressed

While the prevalence of narcotic oversedation in inpatients has not been widely studied, the problem does affect a discrete set of hospitalized patients, with potentially serious consequences.

  • An unquantified but potentially serious problem: There are no systematic studies on the prevalence of narcotic oversedation in inpatients, but the problem undoubtedly exists. FSH retrospectively reviewed all cases where naloxone (a drug designed to reverse the effects of narcotics) was used during a 2-month period in early 2000 and found 11 cases of serious oversedation, representing 0.45 cases per 1,000 discharges.1 Potential consequences of oversedation include respiratory depression (which can be fatal), confusion, lethargy, nausea, vomiting, and constipation.2 Some patients experience harm from narcotics even when dosing is appropriate. Patients with sleep apnea, those who have never used opioids, and the elderly are most susceptible to narcotic oversedation.3
  • A preventable problem: Doses of narcotics must be selected carefully and patients monitored closely to prevent accidental overdoses and adverse drug events.2 The prevalence of narcotic oversedation can be reduced by careful root cause analysis and the systematic and controlled improvement of the processes surrounding narcotic administration and monitoring.3

What They Did

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Description of the Innovative Activity

The FSH program consists of standardized protocols; a pain management team; revised pain management processes in the ORs, recovery rooms, and postoperative floors; and pharmacy support. Key elements of the program are described in more detail below:

  • Standardized protocols and monitoring form: To ensure proper dosage of narcotics and monitoring of patients, providers follow an established set of protocols, including: 1) standard pain assessment and sedation scales; 2) standardized criteria for administering naloxone, and 3) standard order sets for the recovery room. In addition, a new vital signs monitoring form is used to document the pain score, vital signs, and sedation level (which is determined by the respiratory rate in conjunction with the depth of respirations).  
  • Pain management team: The pain management team consists primarily of a clinical nurse specialist and a pharmacist, with support from nurses, pharmacists, anesthetists, a house physician, respiratory therapists, anesthesiologists, and quality resource staff. The team does the following:
    • Reviews cases where patients receive narcotic-reversing drug: The team reviews the case of any patient receiving naloxone. The pain team reviews the charts with the clinical team to look for signs that staff could have recognized to prevent the potential oversedation and the need for naloxone. Originally naloxone events were reviewed retrospectively, but technology advances make it possible for naloxone events to be reviewed almost immediately.
    • Educate staff: The pain team educates staff about available pain medication and how pain management order sets are configured. They also work with staff to help them set realistic pain expectations for the patient. The pain management team also offers training programs for staff on postoperative units (who must demonstrate competency in pain management) and for physicians in outpatient clinics.
    • Provide consultations as needed: The pain management team is available to consult with nurses and doctors on difficult cases.
  • Revised processes in the OR: As part of the interdisciplinary team responsible for monitoring and assessing pain, the OR staff updated their procedures to do the following:
    • Highlight history of sleep apnea: Sleep apnea is often undiagnosed and can lead to potential complications for patients taking narcotics, so the OR team includes questions related to sleep apnea in their preoperative assessment. This information is also provided to the recovery room staff.
    • Increased use of regional anesthesia: When regional anesthesia is used, reduced amounts of systemic narcotic are needed and administered in the OR, thus reducing the cumulative amount of narcotic administered to the patient.
    • Standardization of anesthesia practices: In the past, every anesthesiologist had his/her own method of dosing drugs. That would create the opportunity for confusion in the recovery room. Standardized practice simplifies the process and everyone understands expectations.
  • Revised processes in the recovery room: The recovery room staff has also updated its procedures as part of the interdisciplinary team. Key changes include the following:
    • Increased patient monitoring after narcotics or naloxone: Recovery room staff members now monitor patients who have received a narcotic or naloxone for at least 30 minutes before transferring the patient to the postoperative floor.
    • Revised discharge guidelines: New guidelines require patients to be stable before transferring to a postoperative floor.
  • Revised processes on postoperative floors: Postoperative patients who are not alert enough to manage the patient-controlled analgesia (PCA) pump are now started on the pump on the floor rather than in recovery. In addition, all use of naloxone on postoperative floors is reported to the house physician; oxygen can only be given after a physician order; pulse oximetry is continuously measured; and nurses carry phones to facilitate communication with post-anesthesia care unit (PACU) staff.
  • Pharmacy support: The pharmacy plays an active, ongoing role in assisting caregivers in reducing the potential for oversedation, including the following:
    • Revised usage/dosage guidelines: Pharmacists encourage reduced use of morphine in the recovery room and reduced use of intraoperative doses of fentanyl (pharmacists review all fentanyl patch orders to verify appropriate dosing). The pharmacists also encourage increased use of ketorolac because it is a non-narcotic analgesic, reducing the need to administer narcotics. Pharmacists also established and monitor adherence to dosing guidelines for renal patients and for procedural sedation.
    • Limited access to morphine syringes: Pharmacists removed morphine syringes that are greater than 4 mg from the recovery room floor stock and syringes that are greater than 2 mg from the postoperative floor stock.
    • Standardized PCA orders: Pharmacists developed and monitor adherence to these orders, which include default starting doses, hourly limits, lockout intervals, reversal therapy, and the discouraging of basal rate dosing in most patients. Pharmacists review all orders for basal rates on the PCA to ensure adherence to selection criteria.
    • Epidural protocols: Pharmacists revised and monitor adherence to epidural analgesic orders, and also standardized the volume of epidural analgesic bags.
    • Repackaging: Pharmacists repackaged hydromorphone into 0.2 mg syringes because of dosing errors associated with prepackaged 2 mg syringes.
    • Pharmacy grand rounds: Pharmacists embark on periodic rounds to provide information on appropriate dosing of narcotics, including education about the guidelines highlighted above.

Context of the Innovation

FSH is part of Fairview Health Services, a fully integrated health system in Minneapolis comprising 7 hospitals, 30 primary care clinics, 31 retail pharmacies, a home care and hospice agency, and other programs. In April 2000, hospital administration commissioned an interdisciplinary team, charging them with reducing serious narcotic oversedation by 75 percent. In 2001 the team concluded they had achieved their goal and disbanded. Later that year, when rates of serious narcotic oversedation returned to baseline levels, the team regrouped, re-established the original goal, and began developing the pain management team and other aspects of this program.

Did It Work?

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The program significantly reduced the number of cases of serious narcotic oversedation at FSH and across the Fairview system. 

  • Significant decline in serious narcotic oversedation at FSH: Between 2002 and 2004, FSH averaged 0.45 cases of serious narcotic oversedation per 1,000 discharged patients. By 2006, that rate had fallen by 81 percent, to 0.08 per 1,000 discharged patients. In 2005 there were no cases of serious narcotic oversedation at FSH, while there was only one case in 2006.  
  • System-wide decline as well: Since 2004, the number of cases of serious narcotic sedation fell 60 percent across the entire Fairview system, as other system hospitals implemented the program.

Evidence Rating (What is this?)

Moderate: This evidence consists of pre- and post-implementation comparisons of narcotic oversedation.

How They Did It

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Planning and Development Process

The key steps in the planning and development process included the following:

  • Creation of the pain management team: A clinical nurse specialist and clinical pharmacy specialist were assigned to the pain management team, spending 80 percent and 50 percent of their time respectively on team activities.
  • Creation of written education materials: Pain management staff created wallet-sized cards for providers and posters to remind staff about appropriate use of narcotics in patients.
  • Creation of standardized protocols: The protocols were developed by the pain team in cooperation with and with the approval of the Department of Surgery and the Pharmacy & Therapeutics Committee.

Resources Used and Skills Needed

Staffing: FSH added one full-time clinical nurse specialist and one half-time clinical pharmacy specialist to serve on the pain management team. The University of Minnesota Medical Center and Fairview Ridge Hospital, both part of Fairview Health Services, also have similar staff dedicated to pain management.begin fsxml

Funding Sources

Fairview Health Services
The program was funded internally by Fairview Health Services. end fs

Tools and Other Resources

Adoption Considerations

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Getting Started with This Innovation

  • Secure the active support and engagement of senior management, who are critical in setting aggressive goals, breaking through barriers, and sending the message throughout the organization that this work is of paramount importance.
  • Develop standardized order sets, syringe sizes, sedation scales, and criteria for giving naloxone. Standardized protocols and processes are essential, as variations in individual practice and unit-defined norms can lead to confusion and undermine the quality of care.
  • Allocate dedicated resources, including staff time, from the beginning.  

Sustaining This Innovation

  • Maintain the dedicated resources over time to ensure a comprehensive, standardized, integrated pain management effort.
  • Engage in persistent, relentless measurement to sustain improvements.
  • Recognize that success requires hard work and takes time; do not declare victory too soon.

Use By Other Organizations

FSH initiatives to monitor oversedation are being spread throughout the Fairview Health System, with a system-wide pain committee working to adapt many of these changes to other hospitals within the system.

Additional Considerations

  • All harm is preventable, including but not limited to the harm caused by narcotic oversedation.
  • Narcotic oversedation has multiple root causes; success requires changes in several areas.

More Information

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References/Related Articles

Gulseth MP, Meisel S, Meisel M. Increasing the safety of analgesia use in a community hospital. Am J Health Syst Pharm. 2004;61(11):1143-1146. [PubMed]

Meisel S, Phelps P, Meisel M. Case study: reducing narcotic oversedation across an integrated health system. Jt Comm J Qual Patient Saf. 2007;33(9):543-548. [PubMed]

Meisel M, Meisel S. Best-Practice protocols: reducing harm from high-alert medications. Nurs Manage. 2007;38(7):31-39. [PubMed]

Information about high-alert medications can be found in an Improvement Story by the Institute for Healthcare Improvement online at:


1 Meisel S, Phelps P, Meisel M. Case study: reducing narcotic oversedation across an integrated health system. Jt Comm J Qual Patient Saf. 2007;33(9):543-548. [PubMed]
2 Institute for Healthcare Improvement. High-alert medications require heightened vigilance. April 19, 2007. Available at:
3 Gulseth MP, Meisel S, Meisel M. Increasing the safety of analgesia use in a community hospital. Am J Health Syst Pharm. 2004;61(11):1143-1146. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 23, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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