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Pain is a major public health problem affecting more American adults than heart disease, cancer and diabetes combined. More than 116 million adults in the U.S. suffer from chronic pain, and federal expenditures for pain care total $99 billion a year. Management of pain costs up to $635 billion each year in medical treatment and lost productivity1.

Opioids are an essential tool for the treatment and management of acute, postoperative, and procedural pain, as well as for chronic pain related to cancer in the palliative care setting. However, the use of opioids for chronic pain is more controversial because of the limited evidence surrounding the safety and efficacy of long-term opioid use for chronic pain.

  • Opioids cause a number of adverse drug events that affect patients in both inpatient and outpatient settings.
  • Opioid-related adverse drug events are common in hospitalized patients, with recent estimates confirming a 20% increase in length of stay (LOS) and a 16% increase in costs2.
  • Poorly controlled surgical pain remains as one of the most common reason for re-admissions, including those which are measured in the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP). The HRRP penalizes hospitals by as much as 3% of their total inpatient Medicare revenues.

Addressing ADEs related to unintentional opioid overdoses (i.e., oversedation, respiratory depression) are now among the highest priorities of the Federal Government because of the associated mortality and morbidity. In its recently released ADE Action Plan, the Centers for Medicare and Medicaid Services (CMS) stated that understanding trends in opioid injuries and safe prescribing practices requires accurate, timely, and adequately representative information on key process and outcome measures—at national, regional, and facility levels3. CMS further asserted that currently, few validated metrics are available to assess national- or facility-level burden of opioid ADEs.

To help all stakeholders in pain management and patient safety to more closely understand and continue to address these challenges and concerns, Quantros® recently conducted a study of opioid adverse events and medication errors reported by its hospital and health system customers in 2016.

Specifically, the Quantros® Opioid Adverse Events Benchmarking Study assesses the incidence rate, frequency, severity and the most common contributory factors of opioid adverse events and medication errors, reported by 321 acute care hospitals and other facilities across the continuum of care in 43 U.S. States using Quantros® Safety Event Manager, an incident reporting and risk management solution used by over 250,000 clinicians to monitor, measure and improve patient safety and quality.

The map below illustrates a regional breakout of the acute care facilities that were analyzed in conjunction with the Quantros® 2016 Opioid Adverse Events Benchmarking Study. A total of 12,680 OAE in acute care settings were reported in Quantros’ Safety Event Manager™ system in 2016, representing 13.35% of the total medication events reported in acute care settings.


The National Coordinating Council for Medication Error Reporting and Prevention established a standard to categorize medication errors4. Category A errors have no error but involve circumstances that could cause error. Categories B-D involve errors that resulted in no harm. Category E-F errors are defined as events that caused temporary or permanent harm. Category I means that death occurred, either related to the event or an unknown cause, and Category X errors are those where death occurred due to the admitting diagnosis or due to an unrelated disease.

Of the OAEs reported in 2016 in acute care settings, 7.15% were serious events, reported with Severity E-I.


The most commonly reported contributory factors for the opioid adverse events reported in acute care settings in 2016 include Organization, Management, & Policy Factors and Human Factors, among others. Organizational, Management and Policy factors could include issues such as a lack of availability of clear process, policy and/or procedure. Human factors include competence issues, cognitive factors, or an individual’s failure to comply with policy or protocol.

Amongst all reported opioid medication events reported in 2016, less than 9% of the contributory factors cited human factors involving staff or providers.

Discerning The Relationship between OAE’s and Patient Satisfaction

There is limited, if any, scientific evidence that supports an association between patient satisfaction and opioid adverse events and/or opioid medication errors. Although it does not require patients to specify any particular type of pain control method, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is widely regarded as a reliable framework for measuring patient perceptions of how well hospital staff helps manage their pain.

In an attempt to discern whether such an association could be derived, Quantros correlated the benchmarks for pain control and patient experience contained in the most recent HCAHPS survey reports available on Medicare Hospital Compare with the OAE reporting benchmarks for those hospitals included in this Study. Such correlations reveal that for the top-10 ranked OAE-reporting hospitals by total OAE’s reported, 7 of these are ranked slightly below the national HCAHPS benchmark average for patient satisfaction in pain control.

OAE Lifecycle Analysis

Quantros® also examined when OAEs occurred during the lifecycle of treatment.

Of the reported opioid events, 19.95% of the errors occurred during the administering process, 4.37% occurred in the dispensing process, and 26.3% occurred in “Other.”

Amongst all opioid medication errors that were reported during the administration phase of the treatment lifecycle in 2016, over 5% involved over-dosing or under-dosing of the analgesic therapy.

Opioid Medication Errors: Drug Classifications Profile

Narcotic analgesics made up the majority of reported opioid medication errors that were reported in the dispensed, ordered or administered process. These errors represented 79.4% of those opioid medication errors, while narcotic analgesic combinations made up 25.4% of the errors.


All medication errors must be reported and analyzed to better understand how to prevent future errors from occurring, as these incidents can be harmful and even fatal. Opioid errors, if unchecked, can have catastrophic consequences, as issues with opioids are often more harmful than other medications.

By focusing on three areas — administration of opioids, educating all those involved in the correct policies and protocols, and reporting adverse events in an incident reporting solution — healthcare professionals can have the tools, processes, and actionable data they need to reduce many of the common errors associated with opioids in acute care settings.

Monitoring and tracking these errors allows those in healthcare to identify the types of frequency of errors, understand the issues that occur to contribute the errors, and in time, create protocols to prevent similar errors down the line. The only way to drive improvement is to first understand what is the current landscape is by capturing and documenting the adverse events.

Hospitals and health systems can use the information gathered in a robust incident reporting system to prioritize corrective actions to reduce the prevalence, recurrence, and resulting excess financial consequences of the adverse events.



On behalf of the entire Quantros Executive Leadership Team, I would like to acknowledge and thank the following key contributors to the development and production of this important research study:

  • Morgan Beschle – Director, Product Management
  • Hamsaveni Pasupathy – Research Analyst
  • Anil Javvaji – Research Analyst
  • Christy Quinn – Marketing Manager
  • Amy Lee – Director of Marketing

Very Truly Yours,
Andy Weissberg – 
Senior Vice President of Marketing Communications


Quantros’ mission and vision is to deliver solutions that dynamically monitor risks, measure financial and clinical performance and enable the quality improvements that make care safer. As a trusted value-based partner, our Software-as a-Service (SaaS) applications help thousands of hospitals, retail pharmacies and some of the nation’s largest health systems to capture actionable intelligence, reduce risks and reinforce their commitment to delivering cost-effective, safety-centered, high quality medical care.

Quantros® Safety Risk Management Solutions Suite

The Quantros® Safety and Risk Management Solutions Suite enables healthcare providers to improve quality and patient safety by providing the information they need to prevent errors, improve outcomes, reduce risks and costs. Quantros offers a single access point for users to manage their safety-related claims, risk, event, and reporting activities. The applications support the reduction of patient safety events via automated alerts, real-time reporting and sophisticated root-cause analysis. Organizations can use the application to correct an error prone environment, reducing cost and the loss of internal resources.


1Improving Pain Management for Hospitalized Patients,” Society of Hospital Medicine.
2Cost of Opioid-Related Adverse Drug Events in Surgical Patients,” Oderda, Gary M et al. Journal of Pain and Symptom Management, Volume 25, Issue 3, 276 – 283.
3National Action Plan for ADE Prevention,” The Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 2014.
4Medication Error Index,” National Coordinating Council for Medication Error Reporting and Prevention. Adopted Jul. 16, 1996, Revised Feb. 20, 2001.