Your Resource for HQIC Highlights and Learning Opportunities | Aug. 2021
Preventing Opioid-Related ADEs
An adverse drug event (ADE) is an injury resulting from medical intervention related to a drug.1 This includes medication errors, adverse drug reactions, allergic reactions, and overdoses.

Hospitalized patients frequently experience debilitating pain arising from clinical conditions and treatments. With the common use of opioids in hospitalized patients, opioid-related ADEs (ORADEs) are frequent and serious. Older age, disease severity, length of surgical procedure, and co-prescribed a benzodiazepine are identified as ORADE risk factors.1

Additionally, there is potential for the development of prolonged opioid-use patterns in those exposed to opioids. Opioids prescribed during and after surgery may trigger long-term use in patients regardless of their opioid-tolerance, whether they took opioids regularly prior to surgery, or if they were ever exposed to opioids in the past.2, 3, 4, 5

HSAG HQIC provides tools, resources, and one-on-one technical assistance to hospitals working on preventing ORADEs and implementing an opioid stewardship program. You can find tools here.
The table below indicates the overall baselines and current rates for the HSAG HQIC partnership's opioid progress (lower is better). Your facility’s baselines and current rates may differ. While we celebrate our HSAG HQIC progress, we also continue to focus on improvement and sustainment.
The Flash: Resources
Opioid Stewardship: Patient Education Document to Manage Pain in the Hospital
Some studies suggest that pre-operative pain management education can reduce the use of opioid pain medications and associated ORADEs.6,7 In collaboration with the HSAG Patient and Family Advisory Council (PFAC), HSAG HQIC developed a patient education document to establish realistic pain goals, provide information on Alternatives to Opioids (ALTOS), and incorporate an objective functional scale to complement the Wong-Baker FACES® Pain Rating Scale. 
It Figures—Secure Data Portal
Data and Performance Features
A "Measure Category" section has been added to the portal. You can now view categories such as ADEs, Readmit-Mortality, different types of healthcare-associated infection (HAI), and other harms without excessive scrolling.

There’s more! A "Comparisons Over Time" tab has been added. Select your measure category, measure, and the comparison group to view how you compare to all hospitals in the HSAG HQIC, HSAG HQIC hospitals in your state, like-size hospitals, HSAG HQIC hospitals in HRRP,* those with similar teaching status, and those with comparable urbanicity. 
*HRRP = Hospital Readmissions Reduction Program
Critical Communication
Culture of Safety Assessment Results
Culture of Safety Assessment results can now be downloaded from the Secure Data Portal under the "Reports" tab. Please reach out to your Quality Advisor if you would like to review results together and discuss next steps.
Upcoming Events and Education
HSAG HQIC Quality and Safety Series
The Quality and Safety Series is designed to assist your organization in its quality improvement (QI) journey, from planning and preparation to sustaining gains.

Offered on the 2nd and 4th Tuesdays of the month, these 30-minute-or-less "quickinars" are bite-size learning presentations that review the key skills necessary for you to function in the QI role or for other staff members who are participating in a QI initiative. The quickinars are intended as a basic foundation for the novice or as a skills refresher for the expert.
Quality and Safety Series: 3. Organizational Readiness
Tuesday, August 10, 2021, 2–2:30 p.m. ET
Quality and Safety Series: 4. QI Models
Tuesday, August 24, 2021, 2–2:30 p.m. ET
HSAG HQIC Peer Groups
Peer groups are beginning to meet on a number of subjects. For further details on future peer group sessions, visit the HSAG HQIC online events calendar.
Hospital-Acquired Pressure Injury (HAPI) Peer Group
Tuesday, August 17, 2021, 1–2 p.m. ET
Readmissions Peer Group: Critical Access Hospitals
Session 1
Thursday, August 19, 2021, 12 noon–1 p.m. ET
Readmissions Peer Group: Large Hospitals Session 1
Thursday, August 26, 2021, 12 noon–1 p.m. ET
Reducing Length of Stay, Readmissions, and Cost of Care with Nutrition-Focused Quality Improvement
Thursday, August 12, 2021, 2–3 p.m. ET
This webinar will highlight the role of nutrition as it pertains to reducing hospital readmissions across the continuum of care utilizing an evidence-based approach supporting the use of oral nutrition supplements to improve patient and hospital outcomes.
1Kohn LT, Corrigan JM, Donaldson MS (Institute of Medicine). To err is human: building a safer health system. Washington DC: National Academy Press, 2000. Available at: 
2 Urman et al. The Burden of Opioid‐Related Adverse Drug Events on Hospitalized Previously Opioid‐Free Surgical Patients. Journal of Patient Safety. January 21, 2019. Available at:  
3 Shafi S, Collinsworth AW, Copeland LA, et al. Association of Opioid‐Related Adverse Drug Events With Clinical and Cost Outcomes Among Surgical Patients in a Large Integrated Health Care Delivery System. JAMA Surg. 2018;153(8):757–763. doi:10.1001/jamasurg.2018.1039. Available at:
4 Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg. 2017;125(5):1733–1740. doi:10.1213/ANE.0000000000002458. Available at:
5 Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid‐Naive Patients in the Postoperative Period. JAMA Intern Med. 2016 Sep 1; 176(9):1286–93. Available at:
6 O’Donnell KF. Preoperative pain management education: a quality improvement project. Journal of PeriAnesthesia Nursing, 2015. 30(3), 221-227. Retrieved from
7 Best JT, Musgrave B, Pratt K, et al. The impact of scripted pain education on patient satisfaction in outpatient abdominal surgery patients. Journal of PeriAnesthesia Nursing, 208. 33(4), 453-460. Retrieved from
This material was prepared by Health Services Advisory Group (HSAG), a Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this document do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No. XS-HQIC-XT-07302021-01