title: A single institution's effort to translate codeine knowledge into specific clinical practice.
abstract: BACKGROUND
  Codeine is an unpredictable analgesic because of its variable pharmacokinetic, pharmacodynamic, and pharmacogenetic properties. This variability may lead to ineffective analgesia in some and respiratory depression in others. Despite this, codeine is still widely used. At a pediatric tertiary medical institution, codeine was prescribed despite efforts to inform prescribers of the potentially unpredictable analgesia and serious side effects.
  
  
  METHODS
  A retrospective/prospective metric was introduced to determine the frequency of codeine orders as compared with similar institutions using Pediatric Health Information Systems data.
  
  
  METHODS
  Interventions included formal and informal education to prescribers, and replacing codeine with oxycodone for patients aged older than six months and an age-appropriate medication for those patients younger than six months within ordersets. Identifying and addressing the major barriers to change also was a key part of the process.
  
  
  RESULTS
  Codeine use was reduced by 97% from the first quarter of 2008 through the third quarter of 2012. This was accomplished through orderset changes and education. Codeine was completely eliminated from the hospital formulary in January 2013.
  
  
  CONCLUSIONS
  This quality improvement initiative was successful in eliminating codeine from the hospital formulary. Although education decreased codeine orders, understanding and addressing the barriers to change and directly changing the ordersets were the most effective and efficient for knowledge translation.
authors.affiliation: Boston Children's Hospital, Boston, Massachusetts, USA; Northeastern University, Boston, Massachusetts, USA. Electronic address: jjer0877@gmail.com.
authors.forename: Joel
authors.initials: J
authors.lastname: Jerome
authors.affiliation: Boston Children's Hospital, Boston, Massachusetts, USA.
authors.forename: Jean C
authors.initials: JC
authors.lastname: Solodiuk
authors.affiliation: Boston Children's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Navil
authors.initials: N
authors.lastname: Sethna
authors.affiliation: Boston Children's Hospital, Boston, Massachusetts, USA.
authors.forename: Josh
authors.initials: J
authors.lastname: McHale
authors.affiliation: Boston Children's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Berde
mesh_terms: D000701:Analgesics, Opioid / Q000009:adverse effects / Q000627:therapeutic use*; D002648:Child; D003061:Codeine / Q000009:adverse effects / Q000627:therapeutic use*; D007722:Health Knowledge, Attitudes, Practice; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D010098:Oxycodone / Q000627:therapeutic use; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011446:Prospective Studies; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*
chemical_list: D000701:Analgesics, Opioid; D010098:Oxycodone; D003061:Codeine
keywords: CYP 2D6; Quality improvement; adverse effects; analgesics; codeine; opioid; pain; pediatrics