Opioid Prescribing Rate for Nonoperative Distal Radius Fractures and Clinician Response to a Clinical Decision Support Alert.

BACKGROUND: Opioids are commonly prescribed for the management of acute orthopedic trauma pain, including nonoperative distal radius fractures. OBJECTIVES: This prospective study aimed to determine if a clinical decision support intervention influenced prescribing decisions for patients with known risk factors. We sought to quantify frequency of opioid prescriptions for acute nonoperative distal radius fractures treated. METHODS: We performed a prospective study at one large health care system. Utilizing umbrella code S52.5, we identified all distal radius fractures treated nonoperatively, and the encounters were merged with the Prescription Reporting with Immediate Medication Mapping (PRIMUM) database to identify encounters with opioid prescriptions and patients with risk factors for opioid use disorder. We used multivariable logistic regression to determine patient characteristics associated with the prescription of an opioid. Among encounters that triggered the PRIMUM alert, we calculated the percentage of encounters where the PRIMUM alert influenced the prescribing decision. RESULTS: Of 2984 encounters, 1244 (41.7%) included an opioid prescription. Age increment is a significant factor to more likely receive opioid prescriptions (p < 0.0001) after adjusting for other factors. Among encounters where the physician received an alert, those that triggered the alert for early refill were more likely to influence physicians' opioid prescribing when compared with other risk factors (p = 0.0088). CONCLUSION: Over 90% of patients (106/118) continued to receive an opioid medication despite having a known risk factor for abuse. Additionally, we found older patients were more likely to be prescribed opioids for nonoperatively managed distal radius fractures.

Adherence to legislation limiting opioid prescription duration following musculoskeletal injury.

OBJECTIVES: North Carolina had implemented legislation (Strengthen Opioid Misuse Prevention (STOP) Act) limiting opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain. This study aimed to identify patient, prescriber, and facility characteristics associated with STOP Act adherence for patients with acute or post-surgical musculoskeletal (MSK) conditions. DESIGN: A three-level hierarchical logistic regression model was used to predict odds of adherence with STOP Act duration limits, accounting for fixed and random effects at the patient, prescriber, and facility levels. SETTING: A large healthcare system in North Carolina. PATIENTS AND PARTICIPANTS: Patients (N = 6,849) presenting from 2018 to 2020 with a diagnosis of an acute MSK injury. INTERVENTIONS: The STOP Act limited the duration of opioid prescriptions in North Carolina. MAIN OUTCOME MEASURE: Prescriptions adhering to the STOP Act duration limits of 5 days (nonoperative) or 7 days (operative) were the primary outcome. RESULTS: Opioids were compliant with STOP Act duration limits in 69.3 percent of encounters, with 33 percent of variation accounted for by clinician and 29 percent by facility. Patients prescribed >1 opioid (odds ratio (OR) 0.46, 95 percent confidence interval (CI): 0.36, 0.58) had reduced odds of a compliant prescription; surgical patients had increased odds of a compliant prescription (outpatient surgery: OR 5.89, 95 percent CI: 2.43-14.29; inpatient surgery: OR 7.71, 95 percent CI: 3.04-19.56). Primary care sports medicine clinicians adhered to legislation less frequently than orthopedic surgeons (OR 0.38, 95 percent CI: 0.15, 0.97). CONCLUSIONS: Most prescriptions adhered to STOP Act legislation. Tailored interventions to improve adherence among targeted groups of prescribers, eg, those treating nonoperative injuries and sport medicine clinicians, could be useful.

Implementation of required sedation assessment in nursing workflow to address naloxone utilization.

OBJECTIVE: Opioid-related adverse drug events continue to occur. This study aimed to characterize the patient population receiving naloxone to inform future intervention efforts. DESIGN: We describe a case series of patients who received naloxone in the hospital during a 16-week time frame in 2016. Data were collected on other administered medications, reason for admission to the hospital, pre-existing diagnoses, comorbidities, and demographics. SETTING: Twelve hospitals within a large healthcare system. PATIENTS: 46,952 patients were admitted during the study period. 31.01 percent (n = 14,558) of patients received opioids, of which 158 received naloxone. INTERVENTION: Administration of naloxone. Main outcome of interest: Sedation assessment via Pasero Opioid-Induced Sedation Scale (POSS), administration of sedating medications. RESULTS: POSS score was documented prior to opioid administration in 93 (58.9 percent) patients. Less than half of patients had a POSS documented prior to naloxone administration with 36.8 percent documented 4 hours prior. 58.2 percent of patients received multimodal pain therapy with other nonopioid medications. Most patients received more than one sedating medication concurrently (n = 142, 89.9 percent). CONCLUSIONS: Our findings highlight areas for intervention to prevent opioid oversedation. Investing in electronic clinical decision support mechanisms, such as sedation assessment, could detect patients at risk for oversedation and ultimately prevent the need for naloxone. Coordinated order sets for pain management can reduce the percentage of patients receiving multiple sedating medications and promote the use of multimodal pain management in efforts to reduce opioid reliance while optimizing pain control.

Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting.

OBJECTIVE: The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns. DESIGN: A prospective observational study. SETTING: One large healthcare system. PATIENTS AND PARTICIPANTS: Adult patients presenting with shoulder osteoarthritis. INTERVENTIONS: A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder. MAIN OUTCOME MEASURE: The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures. RESULTS: A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription. CONCLUSION: Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.

Correcting for digital image correlation speckle inversion at high temperature using color cameras.

Digital image correlation (DIC) is a popular, noncontacting technique to measure full-field deformation by using cameras to track the motion of an applied surface pattern. Because it is noncontacting, DIC can be performed for extreme temperature applications (e.g., hot-fire rocket testing of carbon composite rocket nozzles) under harsh conditions during which bonded gauges are damaged. Speckle pattern inversion is a phenomenon that sometimes occurs while performing high-temperature DIC. During speckle pattern inversion, portions of the surface pattern that were initially darker at room temperature (e.g., graphite) may emit more light due to blackbody radiation than the portions that were initially paler, thereby producing images in which the pattern appears inverted at high temperature relative to the initial pattern at room temperature. This phenomenon can prevent the correlation algorithm from being able to resolve the displacements between images. This work compares three methods to mitigate speckle pattern inversion: (A) the subtraction method, a recently-published technique in which two high-temperature images are subtracted to remove unwanted light; (B) the filtering method, a popular technique in which optical bandpass filters screen out unwanted light; and (C) the histogram rescaling method, a proposed new method that pairs a color camera with a blue light source and uses information from the green sensor of the camera to correct against inversion in the blue sensor through postprocessing. The histogram rescaling method is shown to successfully eliminate speckle pattern inversion and has the added advantages that it does not require quasi-static loading to be able to compensate for speckle pattern inversion, nor does it impose thick-glass distortions caused by the optical filter.

Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients.

Introduction: This study reports on the impact of a clinical decision support tool embedded in the electronic medical record and characterizes the demographics, prescribing patterns, and risk factors associated with opioid and benzodiazepine misuse in the older adult population. Significance: This study reports on prescribing patterns for patients ≥65 years-old who presented to Emergency Departments (ED) or Urgent Care (UC) facilities across a large healthcare system following a fall (n = 34,334 encounters; n = 25,469 patients). This system implemented a clinical decision support intervention which provides an alert when the patient has an evidence-based risk factor for prescription drug misuse; prescribers can continue, amend or cancel the prescription. Results: Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid or benzodiazepine prescription. Women and younger patients (65-74) had a higher likelihood of receiving a prescription (P < .0001). 11% had ≥1 risk factor. Women were more likely to receive an early refill (P = .0002) and younger (65-74) men were more likely to have a past positive toxicology (P < .0001). A prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an alert. In 58 cases, the alert resulted in a prescription modification, and in 80 the prescription was canceled. Conclusions: Documented risk for opioid misuse in the elderly was 10% among patients presenting to the ED/UC after a fall. The dangers associated with opioid/benzodiazepine use increase with age as does fall risk. Awareness of risk factors is an important first step; more work is needed to address potentially hazardous prescriptions in this population.

Opioid Prescribing Risk Factors in Nonoperative Ankle Fractures: The Impact of a Prospective Clinical Decision Support Intervention.

Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.

Prevalence of Prescription Opioids for Nonoperative Treatment of Rotator Cuff Disease Is High.

PURPOSE: To quantify the prevalence of opioid and benzodiazepine prescriptions for patients with rotator cuff disease across a large health care system and to describe evidence-based risk factors for opioid use within this population. METHODS: We conducted a retrospective cohort study at a major health care system of all patients with qualifying diagnostic codes. Emergency department, urgent care, and outpatient encounters between January and December 2016 for an acute rotator cuff tear, listed as the primary diagnosis, were included. Encounters with prescriptions for opioids or benzodiazepines were identified using the Prescription Reporting With Immediate Medication Utilization Mapping (PRIMUM) system. Descriptive statistics and the rate of controlled-substance prescribing were calculated for the population as a whole and among subgroups. RESULTS: We identified 9,376 encounters meeting the inclusion criteria. Of these encounters, 1,559 (16.6%) resulted in 1 or more prescriptions for an opioid or benzodiazepine that were issued during the visit. A total of 2,007 opioid and/or benzodiazepine prescriptions were issued for the 1,559 encounters (rate of 1.29 prescriptions per prescribing encounter). This represented 5,310 patients, of whom 1,096 (20.6%) received a prescription for an opioid or benzodiazepine during at least 1 of their encounters. Of patients who received a prescription, 20.9% had at least 1 risk factor for prescription misuse; 3.6% of patients had more than 1 risk factor. There were no demographic differences between patients with risk factors and patients without them. CONCLUSIONS: The prescribing of opioids for the treatment of pain in patients with rotator cuff disease remains high across multiple locations and specialties within a large health care system. Using alternative pain management pathways as primary prevention for opioid misuse and abuse in high opioid-prescribing locations-and especially for patients identified as having a high risk of opioid misuse-is an important practice to continue in our shift away from opioid use as a health care system. LEVEL OF EVIDENCE: Level IV, case series.

Opioid Prescribing and Patient Satisfaction Scores Across Practice Types.

US physicians prescribe opioids at a high rate relative to other countries. Of the US physicians surveyed, almost half report having prescribed an inappropriate opioid due to concerns about patient satisfaction scores. We investigated patterns in controlled substance prescribing practices, patient risk factors, and associated Press Ganey patient satisfaction scores at a sample of orthopaedic surgery and primary care clinics over a 6month time period. Primary care practices had higher proportions of prescriptions, and patient risk profiles varied across sites. However, overall satisfaction was high, with little variation between sites (78.3 81.3%). Satisfaction with pain control was lower and more varied (67.1 78.0%). A total of 4,229 Press Ganey survey responses were received, including 7,232 comments, of which only 10 (0.1%) expressed frustration for not receiving opioids. Opioid prescriptions had minimal association with Press Ganey scores among varied practices and patient populations. Prescribers should prescribe opioids appropriately without fear that this will negatively impact their satisfaction scores. (Journal of Surgical Orthopaedic Advances 29(1):59, 2020).

Establishing an Antimicrobial Stewardship Collaborative Across a Large, Diverse Health Care System.

Alarming trends in antibiotic resistance sparked a National Action Plan endorsing antimicrobial stewardship programs (ASPs) in health care facilities. Atrium Health consists of 28 acute care facilities with varying levels of ASP maturity. The organization sought to establish an ASP collaborative across a diverse network by uniting local resources with a central advisory team. METHODS: In fall 2015 each facility chose a pharmacist, a physician, and an administrative ASP champion. Broad-spectrum antibiotic use was tracked monthly using days of therapy (DOT) per 1,000 patient-days as a standard metric. A gap analysis survey of Centers for Disease Control and Prevention (CDC) core elements for ASPs was conducted to stratify facilities into one of three tiers, with Tier 1 having the most comprehensive ASP. Baseline antibiotic usage data were collected, and DOT reduction goals were set for each facility. Site visits were conducted in winter 2016, and a post-visit summary outlining major goals was provided. Pharmacists held monthly facility meetings to assess progress and a bimonthly virtual meeting for sharing best practices networkwide. In addition, curriculum for an ASP symposium was developed based on identified educational needs. RESULTS: Almost all hospitals (25/28) fully implemented the CDC core elements for ASPs within the first year of establishing the systemwide collaborative. Most facilities (78.6%) achieved their DOT reduction goal ranging from 1%-2.5% to 5%-10%. CONCLUSION: Despite many challenges, building a unified ASP collaborative across a diverse system enabled many hospitals to adopt best practices and improve antimicrobial use.

Prescribing of Opioids and Benzodiazepines Among Patients With History of Overdose.

OBJECTIVES: Addiction and overdose related to prescription drugs continues to be a leading cause of morbidity and mortality in the United States. We aimed to characterize the prescribing of opioids and benzodiazepines to patients who had previously presented with an opioid or benzodiazepine overdose. METHODS: This was a retrospective chart review of patients who were prescribed an opioid or benzodiazepine in a 1-month time-period in 2015 (May) and had a previous presentation for opioid or benzodiazepine overdose at a large healthcare system. RESULTS: We identified 60,129 prescribing encounters for opioids and/or benzodiazepines, 543 of which involved a patient with a previous opioid or benzodiazepine overdose. There were 404 unique patients in this cohort, with 97 having more than 1 visit including a prescription opioid and/or benzodiazepine. A majority of prescriptions (54.1%) were to patients with an overdose within the 2 years of the documented prescribing encounter. Prescribing in the outpatient clinical setting represented half (49.9%) of encounters, whereas emergency department prescribing was responsible for nearly a third (31.5%). CONCLUSIONS: In conclusion, prescribing of opioids and benzodiazepines occurs across multiple locations in a large health care system to patients with a previous overdose. Risk factors, such as previous overdose should be highlighted through clinical decision support tools in the medical record to help prescribers identify patients at higher risk and to mobilize resources for this patient population. Prescribers need further education on factors that place their patients at risk for opioid use disorder and on alternative therapies to opioids and benzodiazepines.

Opioid Prescribing in the Pediatric Orthopaedic Trauma Population.

The purpose of this article is to describe opioid prescribing patterns for children with orthopaedic injuries. A retrospective chart review was conducted on pediatric orthopaedic trauma patients (n = 124) who were discharged from the hospital or emergency department or had a clinic visit during a 1-month period. Patient demographics, prescription specifics, injury details, and fracture fixation information were collected. Results show that most children received opioids after injury (82.3%). While children undergoing operative fixation typically received opioids, only 39.5% with closed reduction did. Hydrocodone- acetaminophen accounted for 93% of prescriptions, but adolescents were more likely to receive other drugs. There was a significant trend of increasing daily dosage with increased age; 36.73% of adolescents received > 50 morphine milligram equivalents per day. Children with orthopaedic injuries are typically prescribed opioids; older children more commonly receive higher dosages. Further study is needed to define prescribing trends across facility and specialty types to aid in development of standardized prescribing guidelines. (Journal of Surgical Orthopaedic Advances 27(4):269-273, 2018).

Blood flow patterns during incremental and steady-state aerobic exercise.

BACKGROUND: Endothelial shear stress (ESS) is a physiological stimulus for vascular homeostasis, highly dependent on blood flow patterns. Exercise-induced ESS might be beneficial on vascular health. However, it is unclear what type of ESS aerobic exercise (AX) produces. The aims of this study are to characterize exercise-induced blood flow patterns during incremental and steady-state AX. We expect blood flow pattern during exercise will be intensity-dependent and bidirectional. METHODS: Six college-aged students (2 males and 4 females) were recruited to perform 2 exercise tests on cycle-ergometer. First, an 8-12-min incremental test (test 1) where oxygen uptake (VO2), heart rate (HR), blood pressure (BP), and blood lactate (La) were measured at rest and after each 2-min step. Then, at least 48-hr. after the first test, a 3-step steady state exercise test (test 2) was performed measuring VO2, HR, BP, and La. The three steps were performed at the following exercise intensities according to La: 0-2 mmol/L, 2-4 mmol/L, and 4-6 mmol/L. During both tests, blood flow patterns were determined by high-definition ultrasound and Doppler on the brachial artery. These measurements allowed to determine blood flow velocities and directions during exercise. RESULTS: On test 1 VO2, HR, BP, La, and antegrade blood flow velocity significantly increased in an intensity-dependent manner (repeated measures ANOVA, P<0.05). Retrograde blood flow velocity did not significantly change during test 1. On test 2 all the previous variables significantly increased in an intensity-dependent manner (repeated measures ANOVA, P<0.05). CONCLUSIONS: These results support the hypothesis that exercise-induced ESS might be increased in an intensity-dependent way and blood flow patterns during incremental and steady-state exercises include both antegrade and retrograde blood flows.

The Importance of Team Sex Composition in Team-Training Research Employing Complex Psychomotor Tasks.

OBJECTIVE: The relationship between team sex composition and team performance on a complex psychomotor task was examined because these types of tasks are commonly used in the lab-based teams literature. BACKGROUND: Despite well-documented sex-based differences on complex psychomotor tasks, the preponderance of studies-mainly lab based-that use these tasks makes no mention of the sex composition of teams across or within experimental conditions. METHOD: A sample of 123 four-person teams with varying team sex composition learned and performed a complex psychomotor task, Steal Beasts Pro PE. Each team completed a 5-hr protocol whereby they conducted several performance missions. RESULTS: The results indicated significant large mean differences such that teams with larger proportions of males had higher performance scores. CONCLUSION: These findings demonstrate the potential effect of team sex composition on the validity of studies that use complex psychomotor tasks to explore and investigate team performance-related phenomena when (a) team sex composition is not a focal variable of interest and (b) it is not accounted for or controlled. APPLICATION: Given the proclivity of complex psychomotor action-based tasks used in lab-based team studies, it is important to understand and control for the impact of team sex composition on team performance. When team sex composition is not controlled for, either methodologically or statistically, it may affect the validity of the results in teams studies using these types of tasks.

Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts.

BACKGROUND: Alerts generated by intravenous (IV) infusion pump safety software prevent life-threatening situations that might otherwise go unnoticed. However, when alerts are often clinically insignificant, health care workers may become desensitized and discount their importance, resulting in potentially dangerous situations. Little research has been devoted to visual alert desensitization. METHOD: This paper describes how the Carolinas HealthCare System decreased the number of nonclinically relevant infusion pump alerts by analyzing alert data that were formatted into scatter plots. This in turn enabled the identification of the medications associated with the most meaningful alerts and those associated with the least meaningful alerts. CONCLUSION: By revising drug library limits for specific medications, it was possible to decrease the number of less clinically meaningful alerts, reduce alert fatigue, and thereby increase the effectiveness of the smart infusion pumps. This added another layer of safety to patient care.

Biosimilars Are Here: A Hospital Pharmacist's Guide to Educating Health Care Professionals on Biosimilars.

BACKGROUND: Pharmacists are the recognized experts in pharmacotherapy. With the recent introduction of biosimilar agents into the US market, pharmacists are poised to play a pivotal role in evaluating their risks versus benefits within the framework of cost containment. PURPOSE: This article provides hospital pharmacists with the necessary information on the principles surrounding the development, approval process, and use of biosimilars. METHODS: Information contained in this article enables hospital pharmacists to identify concerns relating to biosimilars, implement educational components, and successfully evaluate biosimilars for the addition to the formulary. Additionally, this article reviews the European experience with biosimilars, the US Food and Drug Administration approval process, and postauthorization safety and pharmacovigilance programs. CONCLUSION: It is important to educate health care providers about the differences between biosimilars and their reference biologics. The adoption of biosimilars is necessary to control long-term costs of biologics, increase patient access to care, and encourage innovation.

Comparative evaluation of three situational judgment test response formats in terms of construct-related validity, subgroup differences, and susceptibility to response distortion.

As a testing method, the efficacy of situational judgment tests (SJTs) is a function of a number of design features. One such design feature is the response format. However, despite the considerable interest in SJT design features, there is little guidance in the extant literature as to which response format is superior or the conditions under which one might be preferable to others. Using an integrity-based SJT measure administered to 31,194 job applicants, we present a comparative evaluation of 3 response formats (rate, rank, and most/least) in terms of construct-related validity, subgroup differences, and score reliability. The results indicate that the rate-SJT displayed stronger correlations with the hypothesized personality traits; weaker correlations with general mental ability and, consequently, lower levels of subgroup differences; and higher levels of internal consistency reliability. A follow-up study with 492 college students (Study 2; details of which are presented in the online supplemental materials) also indicates that the rate response format displayed higher levels of internal consistency and retest reliability as well as favorable reactions from test takers. However, it displayed the strongest relationships with a measure of response distortion, suggesting that it is more susceptible to this threat. Although there were a few exceptions, the rank and most/least response formats were generally quite similar in terms of several of the study outcomes. The results suggest that in the context of SJTs designed to measure noncognitive constructs, the rate response format appears to be the superior, preferred response format, with its main drawback being that it is susceptible to response distortion, although not any more so than the rank response format.

Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety.

BACKGROUND: Safety software installed on intravenous (IV) infusion pumps has been shown to positively impact the quality of patient care through avoidance of medication errors. The data derived from the use of smart pumps are often overlooked, although these data provide helpful insight into the delivery of quality patient care. OBJECTIVE: The objectives of this report are to describe the value of implementing IV infusion safety software and analyzing the data and reports generated by this system. CASE STUDY: Based on experience at the Carolinas HealthCare System (CHS), executive score cards provide an aggregate view of compliance rate, number of alerts, overrides, and edits. The report of serious errors averted (ie, critical catches) supplies the location, date, and time of the critical catch, thereby enabling management to pinpoint the end-user for educational purposes. By examining the number of critical catches, a return on investment may be calculated. Assuming 3,328 of these events each year, an estimated cost avoidance would be $29,120,000 per year for CHS. Other reports allow benchmarking between institutions. CONCLUSION: A review of the data about medication safety across CHS has helped garner support for a medication safety officer position with the goal of ultimately creating a safer environment for the patient.