Challenge 4

Failure to Rescue: Monitoring for Opioid Induced Respiratory Depression

Executive Summary Checklist

Opioid induced respiratory depression is a leading cause of totally preventable patient death (Joint Commission, 2012; ISMP, 2007; Weinger et al., 2011). It also causes serious patient harm. Patients receiving opioids in the hospital have almost twice the incidence of cardiorespiratory arrest compared to other patients (Overdyk et al., 2016).

  • Implement continuous electronic monitoring on all floors where patients are receiving opioid medications.
  • Make continuous (not spot-check) monitoring of oxygenation the care standard. At a minimum, monitoring should include continuous measure through motion and low perfusion pulse oximetry (e.g. Masimo SET, Nihon Kohden OxyPal Neo, Nellcor N-600, Philips Intellivue MP5 in a standalone bedside device or integrated in one of over 100 multi-parameter bedside monitors) with a central monitoring station with direct, immediate communication to the nurse on a mobile device. (Louie et al.,2017)
  • Monitor respiratory rate in patients receiving supplemental oxygen with either continuous capnography or acoustic respiration rate monitoring are technologies that can achieve this.
  • Set appropriate respiratory rate (RR) alarms and apnea alarms to minimize alarm fatigue based on the patient population and individual risk of respiratory compromise.
    • For example, in adults, RR between 6 and 30 breaths per minute, pulse rate (PR) between 40 and 100.
    • For example, in pediatrics, PR between 70-120 for pediatric patients and a lower limit of 84% for SpO2 (McGrath et al, 2016).
  • Institute a rapid response notification system, which will 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 patient deaths and serious patient harm events over the previous 24 months where opioids were involved and may have contributed to the event. A review of all previous closed malpractice claims related to opioid induced respiratory depression should also be undertaken.
    • Monitor and review all patients where naloxone was administered.
    • Identifying and prioritizing common contributing factors from those serious preventable events.
    • Identify and institute continuous electronic monitoring technologies that notify staff of significant changes in a patient’s respiratory condition, and ensure appropriate interventions are initiated in a timely manner.
    • Providing the resources necessary to implement the action 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.
    • Implementation of a plan that eliminates current risks associated with opioids.
    • Continuing to report and assess both near misses and patient harm events for additional learning opportunities and improvement.
  • Develop a multimodal analgesic pain management program utilizing non-opioid adjuncts.
  • Patients and caregivers should be educated to recognize potential side effects of opioids and sedatives, and notify caregivers immediately if they occur.

The Performance Gap

Complications are inevitable and they are not always avoidable or the result of errors. However, when a patient dies because of a complication that was not recognized in a timely manner or treated appropriately, that death is preventable and is called “Failure to Rescue.” Technology and knowledge now exist to

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