Project Information

Evaluation of Naloxone Administrations in the Past 12 Months at UF Health Shands Hospital

Project Description: In order to address the opioid crisis and improve patient safety, The Joint Commission (TJC) recently published new standards for pain management in the hospital setting including a requirement for hospitals to monitor the safe use of opioids. TJC recommends strategies such as tracking naloxone use and opioid related adverse events to fulfil this requirement. TJC notes that hospitals who monitored the use of naloxone were able to significantly reduce adverse events related to opioid use and identify areas of improvement for patient safety and quality of care. The UF Health Shands accreditation team in collaboration with the pain committee is responsible for ensuring adequate systems are in place to meet the intent of these newly proposed pain management standards. The intent of this medication use evaluation (MUE) is to characterize non-critically ill hospitalized patients who experienced respiratory depression or over-sedation due to opioid medications, along with their care processes. Data collection would seek to identify patients with preventable adverse drug reactions (pADRs), determine risk factors for the development of adverse outcomes with opioids, and identify areas within the system of care that can be improved to prevent these events in the future. The results of this MUE will be presented to the pain committee to assist the committee in implementing systems strategies to enhance the safe use of opioid medications in the hospital. Reference: Pain Assessment and Management Standards for Hospitals; R3 Report Requirement, Rationale, Reference; The Joint Commission, Issue 11, August 29, 2017

QPI: Aklil, Hiruy, (


Advisors: Amy, Rosenberg, (

UF Health Big Aims: Zero Harm None

MeSH Keywords: Analgesics, Opioid, Naloxone, Pain Management, Patient Safety, Drug-Related Side Effects and Adverse Reactions