Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital

BMJ Quality and Safety

Volumn 20, Issue 10, 2011, Pages 895-902

  Vermaire, Deborah ^a   Caruso, Michelle C ^a   Lesko, Anne ^a   Kloppenborg, Elizabeth ^a   Olivea, Jason ^a   Pruett, Raymond ^a   Paul, Marika ^a   Schoettker, Pamela J ^a   Seid, Michael ^a   Varadarajan, Kartik R ^a   Conway, Patrick H ^a  

^a CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

FENTANYL; HYDROMORPHONE; MORPHINE; NALOXONE; NARCOTIC ANALGESIC AGENT;

ADOLESCENT; ADULT; ANALGESIA; ARTICLE; CHILD; DISEASE SEVERITY; DRUG OVERDOSE; FEMALE; HEALTH CARE QUALITY; HUMAN; INFANT; MAJOR CLINICAL STUDY; MALE; NURSE; PAIN; PERIOPERATIVE PERIOD; PRESCHOOL CHILD; PRESCRIPTION; SCHOOL CHILD; SEDATION;

ADOLESCENT; ADULT; ANALGESIA, PATIENT-CONTROLLED; ANALGESICS, OPIOID; CHILD; CHILD, PRESCHOOL; FEMALE; HOSPITALS, PEDIATRIC; HUMANS; INFANT; INFANT, NEWBORN; MALE; OVERDOSE; PERIOPERATIVE PERIOD; QUALITY IMPROVEMENT; SOCIOECONOMIC FACTORS;

EID: 80053281000     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs.2010.044065     Document Type: Article

References (24)

1. Leape LL, Kabcenell A, Berwick DM, et al. Reducing adverse drug events: breakthrough series guide. 1998. http://www.ihi.org/IHI/Topics/PatientSafety/ SafetyGeneral/Literature/ReducingAdverseDrugEventsBreakthroughSeriesGuide.htm (accessed 8 Apr 2010).
2. Sharek PJ, McClead RE Jr, Taketomo C, et al. An intervention to decrease narcotic-related adverse drug events in children's hospitals. Pediatrics 2008;122:e861-6.
3. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-20. (Pubitemid 32367829)
4. Takata GS, Mason W, Taketomo C, et al. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics 2008;121:e927-35.
5. Frasco PE, Sprung J, Trentman TL. The impact of the joint commission for accreditation of healthcare organizations pain initiative on perioperative opiate consumption and recovery room length of stay. Anesth Analg 2005;100:162-8. (Pubitemid 40013623)
6. Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA 2000;284:428-9.
7. Institute for Safe Medication Practices. Pain scales don't weigh every risk. ISMP Medication Safety Alert, 2002. http://www.ismp.org/Newsletters/ acutecare/articles/20020724.asp (accessed 8 Apr 2010).
8. Vila H Jr, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings. Anesth Analg 2005;101:474-80. (Pubitemid 41045233)
9. Taylor S, Voytovich AE, Kozol RA. Has the pendulum swung too far in postoperative pain control? Am J Surg 2003;186:472-5. (Pubitemid 37352830)
10. Taylor S, Kirton OC, Staff I, et al. Postoperative day one: a high risk period for respiratory events. Am J Surg 2005;190:752-6. (Pubitemid 41446500)
11. Britto MT, Anderson JM, Kent WM, et al. Cincinnati Children's Hospital Medical Center: transforming care for children and families. Jt Comm J Qual Patient Saf 2006;32:541-8.
12. Muething SE, Conway PH, Kloppenborg E, et al. Identifying causes of adverse events detected by an automated trigger tool through indepth analysis. Qual Saf Health Care 2010;19:435-9.
13. Langley GJ, Nolan KM, Nolan TW, et al. The improvement guide. A practical approach to enhancing organizational performance. San Francisco: Jossey-Bass, 1996.
14. Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991;266:2847-51.
15. Eckstrand JA, Habib AS, Williamson A, et al. Computerized surveillance of opioid-related adverse drug events in perioperative care: a cross-sectional study. Patient Saf Surg 2009;3:18.
16. Ramsay MA, Savege TM, Simpson BR, et al. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974;2:656-9.
17. Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care 2003;12:194-200. (Pubitemid 36723946)
18. Merkel SI, Voepel-Lewis T, Shayevitz JR, et al. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293-7.
19. Myles PS, Troedel S, Boquest M, et al. The pain visual analog scale: is it linear or non-linear? Anesth Analg 1999;89:1517-20.
20. Lawrence J, Alcock D, McGrath P, et al. The development of a tool to assess neonatal pain. Neonatal Netw 1993;12:59-66.
21. McGrath PJ, Johnson G, Goodman JT, et al. CHEOPS: a behavioral scale or rating postoperative pain in children. In: Fields H, Dubner R, Cervero F, eds. Advances in pain research and therapy. vol. 9. New York: Raven Press, 1985:395-402.
22. Amin SG. Control charts 101: a guide to healthcare applications. Qual Manag Health Care 2001;9:1-27.
23. Provost L, Murray S. The data guide. Learning from data to improve healthcare. Austin, TX: Associated in Process Improvement, Corporate Transformation Concepts, 2007.
24. Luria JW, Muething SE, Schoettker PJ, et al. Reliability science and patient safety. Pediatr Clin North Am 2006;53:1121-33. (Pubitemid 44779683)