title: 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?
abstract: Inadequate analgesia in hospitalized patients prompted the Joint Commission on Accreditation of Healthcare Organizations in 2001 to introduce standards that require pain assessment and treatment. In response, many institutions implemented treatment guided by patient reports of pain intensity indexed with a numerical scale. Patient safety associated with treatment of pain guided by a numerical pain treatment algorithm (NPTA) has not been examined. We reviewed patient satisfaction with pain control and opioid-related adverse drug reactions before and after implementation of our NPTA. Patient satisfaction with pain management, measured on a 1-5 scale, significantly improved from 4.13 to 4.38 (P < 0.001) after implementation of an NPTA. The incidence of opioid over sedation adverse drug reactions per 100,000 inpatient hospital days increased from 11.0 pre-NPTA to 24.5 post-NPTA (P < 0.001). Of these patients, 94% had a documented decrease in their level of consciousness preceding the event. Although there was an improvement in patient satisfaction, we experienced a more than two-fold increase in the incidence of opioid over sedation adverse drug reactions in our hospital after the implementation of NPTA. Most adverse drug reactions were preceded by a documented decrease in the patient's level of consciousness, which emphasizes the importance of clinical assessment in managing pain.
  
  
  CONCLUSIONS
  Although patient satisfaction with pain management has significantly improved since the adoption of pain management standards, adverse drug reactions have more than doubled. For the treatment of pain to be safe and effective, we must consider more than just a one-dimensional numerical assessment of pain.
authors.affiliation: Department of Interdisciplinary Oncology, Department of Performance Improvement, Biostatistics and Informatics Core, Palliative Care, The H. Lee Moffitt Cancer Center and Research Institute, A National Cancer Institute; and the Department of Anesthesiology, University of South Florida College of Medicine, Tampa, Florida.
authors.forename: Hector
authors.initials: H
authors.lastname: Vila
authors.forename: Robert A
authors.initials: RA
authors.lastname: Smith
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Augustyniak
authors.forename: Peter A
authors.initials: PA
authors.lastname: Nagi
authors.forename: Roy G
authors.initials: RG
authors.lastname: Soto
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Ross
authors.forename: Alan B
authors.initials: AB
authors.lastname: Cantor
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Strickland
authors.forename: Rafael V
authors.initials: RV
authors.lastname: Miguel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000701:Analgesics, Opioid / Q000009:adverse effects / Q000627:therapeutic use; D062787:Drug Overdose; D005260:Female; D017408:Guidelines as Topic; D006761:Hospitals / Q000592:standards*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D059408:Pain Management; D010147:Pain Measurement / Q000592:standards*; D017060:Patient Satisfaction; D012449:Safety
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives