This AHRQ-funded study describes the implementation of an Institute for Healthcare Improvement–style quality improvement collaborative aimed at reducing narcotic-related adverse drug events (ADEs). Fourteen participating hospitals adopted a series of recommended interventions while tracking ADE rates in a pre- and postintervention study design. Investigators discovered a 67% reduction in narcotic-related ADE rates, and also noted decreased rates of constipation and automated drug-dispensing overrides in patients receiving narcotic therapy. The authors point out several limitations to the study, including the inability to measure compliance with the intended change packages at each hospital. This study provides a nice example of the challenges in evaluating multifaceted quality improvement interventions despite its successful outcomes.