Challenge 4

Failure to Rescue: Monitoring for Opioid Induced Respiratory Depression

Executive Summary Checklist

Opioid-induced respiratory depression is a leading cause of preventable patient death and serious patient harm events. Hospital leadership must understand, appreciate and commit to eliminating these events. Implementing an effective program to reduce opioid-induced respiratory depression will require an implementation plan to complete the following actionable steps:

  • Implement continuous electronic monitoring on all floors where patients are being administered opioids and are in bed.
  • Monitoring should consist of a minimum SET (Measure Through Motion and Low Perfusion) pulse oximetry with a central telemetry station; direct communication to the nurse on her “smart phone” is preferred.
  • Patients receiving supplemental oxygen should also have ventilation monitored (e.g. capnography or acoustic rate monitoring).
  • Set respiratory rate alarms to minimize alarm fatigue (e.g. 6 breaths per minute at the low end and 30 breaths per minute at the high end, with a 30 sec delay and a 15 sec notification delay.)
  • A rapid response notification system should be in place to alert staff if the patient is deteriorating. A plan for escalation of rapid response alarm to another staff member should also be in place.
  • Hospital governance should commit to a plan that includes:
    • Reviewing all reported preventable patient deaths and serious patient harm events over the previous 24 months where opioids were involved and may have contributed to the preventable event. A review of all previous closed malpractice claims related to opioid-induced respiratory depression should also be undertaken.
    • Identifying and prioritizing common contributing factors from those serious preventable events.
    • Identifying continuous electronic monitoring technologies that notify staff of significant changes in a patient’s respiratory condition which includes a rapid response approach that ensures appropriate interventions are initiated in a timely manner.
    • Providing the resources necessary to implement the chosen plan.
    • Identifying a hospital “champion” who will be accountable for successful implementation, education and evaluation of the chosen plan.
    • Developing an educational plan for all staff, patients and family members that shares common contributing factors leading to opioid-induced respiratory depression as well as the implementation plan that strives to eliminate current risks associated with opioids.
    • Continuing to report and assess both near misses and patient harm events for additional learning opportunities and improvement.

Between the 2017 World Patient Safety, Science & Technology Summit and the 2017 Midyear Planning Meeting a workgroup comprised of experts representing administrators, clinicians, technologists and patient advocates will meet to update this APSS. If you are interested in joining this workgroup, please email us.