In the last 8 years, the testing and treatment of pain have become a priority for medical care organizations, especially after the formation of regulatory standards and patient surveys directly correlating pain management with a favorable effectiveness score. While much of the focus is on adding the number of patients receiving effective pain relief, there has been a subsequent increase in overaggressive testing to ensure comfort . Severe acute pain is best treated with timely, intravenous doses of opioids, which allow quick titration of effect. Appropriately and accurately prescribed patient-controlled analgesia (PCA) is an effective method of pain management; the risk of oversedation is reduced, and there is a greater potential to improve pain management for patients . PCA allows patients to self-administer more frequent but smaller doses of narcotics than the traditional nurse-administered larger and less frequent doses, thus making PCA a favorable choice to comply with pain management standards and patients' goals for comfort. PCA offers distinct advantages when protocols are in place to assess the level of pain; and the rate, depth, and quality of respirations; and note whether the patient is opioid tolerant or not. However, unintended consequences such as oversedation, respiratory depression, and undertreated pain may occur from the use of PCA. Contributing factors that lead to these events include improper patient selection, inadequate patient monitoring, pump programming errors, PCA by proxy, patients' self-administration of home medicine while receiving PCA, imprudent polypharmacy, and insufficient health care team member training or education about medications administered via PCA and their dosing and lockout periods. Adverse events due to one of these many contributing factors are preventable and can be significantly reduced with guidance for treatment team staff, patients, and family member . Based on these warnings, many facilities have formed, team-based approaches to review PCA-related measures to address the leading factors to these events. Much of the focus is on five pain management areas: patient selection, prescribing errors, medical staff training, and pain management patient education. Developing advanced criteria for selecting patients to receive PCA is one of the most overlooked but preventable mechanisms to significantly affect events. . Patients are considered opioid tolerant if they receive at least 60 mg daily of oral morphine, at least 25 mcg/hr of transdermal fentanyl, at least 30 mg daily of oral oxycodone, at least 8 mg daily of oral hydromorphone, or an equianalgesic daily dose of another opioid for at least a week. Patients not meeting this definition would be termed opioid naive. Assessing a pain management patient's opioid status may facilitate ordering the most effective initial dose. .