DOWNLOAD THE POSTEROpioids are used for rapid pain management in hospital settings. They are considered a high risk medication group as when errors occur consequences for the patient are more serious. Recent New Zealand national data has found that opioids (33 percent) were most commonly implicated for causing adverse drug events. As a result of the Health Quality and Safety Commission (HQSC) sponsoring the ten month Institute for Healthcare Improvement (IHI) – Improvement Advisor (IA) Professional Development programme (Wave 29 – June 2013 to March 2014), CCDHB had the opportunity to focus on a project that would provide an opportunity to apply the theory and methods learned in the IA program and be strategically important to CCDHB. At CCDHB we had four serious event reviews involving opioid use. Opioids were identified as a key medication safety work stream at CCDHB, and subsequently “Safe use of opioids at CCDHB” was chosen as one of the CCDHB IHI IA projects.