Our institution's rapid response team (RRT) data regarding interventions during RRT visits indicated a trend for increased Narcan administration for patients on our orthopedic surgery unit.


To identify the root cause of increased need for Narcan administration in this patient population and to implement strategies to resolve the problem.


During an ongoing performance improvement process of reviewing RRT data for trends, there was noted a marked increase in the administration of Narcan during RRT visits on orthopedic surgery patients. Our RRT nurse‐practitioners reviewed the medical records for these patients and noticed most had postsurgery preprinted order sets. The section for pain management on these order sets gave a variety of choices and ranges for oral and intravenous (IV) analgesics. On further review, the range for IV dilaudid was quite broad, with a maximum IV dose of 3 mg. The RRT nurse‐practitioners conducted informal interviews with the nursing staff of the orthopedic unit to find out how the staff nurses decided what analgesic dose to administer using the order sets. These interviews revealed there was no consistency regarding decision‐making among the staff nurses. Another important piece of information revealed during these interactions was that most staff nurses were unaware of the equivalent dosing comparisons of dilaudid versus morphine sulfate. Many nurses believed there was a milligram‐to‐milligram equivalency between the 2 drugs and were unaware of how much more narcotic was in 3 mg of dilaudid versus 3 mg of morphine sulfate. The RRT nurse‐practitioners immediately put together an educational program and poster for the orthopedic nursing staff and began rounding on the unit multiple times a day for a week to ensure each staff member was reached. The RRT nurse‐practitioners also collaborated with the unit nursing director, medical director, and medical staff to revise the order sets to limit analgesic dosing options.


Although the administration of Narcan is still an occasional needed intervention during an RRT visit, the orthopedic surgery patient population no longer stands out in the crowd. Ongoing review of RRT data is an excellent opportunity to identify possible trends that impact patient care.

Author Disclosure:

M. Williams, none.