Clinical outcomes measurement: Naloxone utilization monitoring to improve institutional pain management practices

Abstract

The objectives of this study are to evaluate the utility of automated naloxone use reports and chart reviews to detect medication errors and adverse effects in pain management. Also, to determine the effectiveness of education as tool for process improvement in pain management, specifically opioid use, prevention of adverse effects, and minimizing medication errors. It has been estimated that over one million U.S. hospitalized patients are injured by medical errors each year and approximately 180,000 die as a result. National attention has focused on the occurrence, clinical consequences, and costs of injuries in hospitals, which are estimated at $2 billion annually in the United States.. Until recently, little attention has been given to understanding causes of these errors, or developing methods to prevent them. This may be because medical injuries seem to have few common causes, but also there was a general lack of awareness of the problem. Chart review for naloxone use at an institution can provide direct and specific feedback on adverse drug reaction patterns. Review of this usage can be a useful tool to assess the need for education and process improvement. The cost associated with implementation of type of monitoring is minimal. A recent survey by a member of the American Pain Society revealed that only 35% of surveyed institutions used chart review of naloxone use as a tool to improve pain management. An 81% reduction in opioid related adverse effects and medication errors resulted after intensive education and direct feedback to hospital staff. In conclusion, opioid related errors and adverse effects can be significantly reduced by monitoring naloxone utilization.