Overview:

• The team quickly identified an opportunity to remove morphine from a postoperative orthopedic order set following a safety event. They redesigned a malfunctioning extended-release opioid order panel to drive appropriate base-level dosing for opioid-naive and opioid-tolerant patients.
• As a result, the team found insight that prevented potential postoperative safety events and convinced leadership to prioritize fixing an extended-release opioid order panel.

PROBLEM

Penn Medicine established an Opioid Task Force in 2017 in response to the national opioid epidemic. The program aims to prevent adverse consequences associated with prescribing opioids. Recently, the team was tasked with investigating a safety event where an orthopedic surgery patient received a high dose of morphine postoperatively; the team needed accessible data to figure out what went wrong. Additionally, while navigating their data, the team found an opioid order panel that was broken and were additionally tasked with providing sufficient documentation for IT to prioritize its fix.

APPROACH

The team turned to Phrase Health for easy access to orders data. They reviewed the orthopedic order set and quickly saw how often and under what circumstances morphine was ordered. They found that the safety event encounter was the only time that morphine was ordered from the orthopedic order set, and that the dosage was dangerous for an opiate-naive patient. Armed with Phrase Health data, the team was able to convince leadership that the morphine order was a hazard and could be removed from the order set to improve safety.

While navigating Phrase Health data insights, the team also identified a broken extended-release opioid order panel that was barely being used. The team determined that the order panel was experiencing low usage because the panel was shown at the bottom of the facility list and was not on the preferred list in the electronic health record (EHR). The team used the low utilization data from Phrase Health to convince the IT team that changes needed to be made.

RESULT

The team’s recommendations improved patient safety and prevented future safety events. Removing morphine from the orthopedic order set will prevent surgery patients from receiving the wrong post-op medication, and fixing the extended-release opioid order panel will ensure that patients will receive the correct opioid dosage based on their level of tolerance.