Led by pediatric nurse practitioner Michele Bythrow, the institution-wide program utilized automated electronic health record alerts to prompt clinicians during the discharge process. By integrating these digital tools with comprehensive education for families, nurses, and pharmacists, the hospital bridged a significant gap in pediatric safety standards. Prior to this shift, naloxone—a critical overdose-reversal medication—was rarely discussed or prescribed for young patients despite the documented risks of accidental poisoning and misuse.

Between October 2023 and June 2025, the effort faced hurdles regarding medication costs and perceived stigma. To mitigate these issues, the CHOP team partnered with outpatient pharmacies to expand access to a Pennsylvania state discount program, previously restricted to adult patients. While nearly 60% of the prescribed doses were filled through hospital pharmacies, the team is now positioning this framework as a scalable model for other pediatric systems aiming to formalize opioid safety practices.