Challenge 4

Failure to Rescue: Monitoring for Opioid Induced Respiratory Depression

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." While opioid use is safe for most patients, opioid analgesics are associated with adverse effects and cause respiratory depression in a significant number of post-surgical patients, who often receive them for pain management.

Each Actionable Patient Safety Solutions (APSS) includes an Executive Summary Checklist, Performance Gap, Leadership Plan, Practice Plan, Technology Plan and Metrics. Please click Download below to view the full document. A preview of the Executive Summary is offered below.

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.


Failure to rescue accounts for 60,000 deaths each year in Medicare patients under age 75.1

HealthGrades Quality Study. (2004, July). Patient safety in American hospitals. Retrieved from:

Incidence rate of failure to rescue is 8-16.9%.2

Johnston, M.J. et al. (2015, April). A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery, 157 (4), 752-763. Retrieved from

The majority of failure to rescue cases on nursing unites are progressive; that education of the nursing staff along with the utilization of those monitoring tools is what is key to the success of being able to identify and immediately intervene before the patient begins to get into trouble.3

Susan Lorenz, DrNP, RN, NEC-BEC, EDAC, Vice President of Patient Care Services and Chief Nursing Officer, Princeton HealthCare System.

68% of all failure-to-rescue deaths occur among surgical inpatients with treatable complications, pressure ulcers, post-operative respiratory failure, and post-operative sepsis.4

Reed and May, HealthGrades Patient Safety in American Hospitals Study, March 2011.