Saving Lives Through Continuous Post-Operative Monitoring

“Failure to Rescue” is when a patient dies from a medical complication that was not recognized in a timely manner or treated appropriately; these deaths are preventable, costly, and all too common.

  • The Joint Commission reports that from 2004-2011, one in three opioid-related adverse drug events—including deaths—was related to improper monitoring of the patient.1
  • Failure to Rescue from post-operative opioid events can be prevented through continuous monitoring using pulse oximetry to measure blood oxygenation and respiration rate.2
  • There is currently no law requiring continuous monitoring of post-operative patients on opioids, enacting legislation would save the Medicare Program $1 Billion annually.3

Pulse oximetry is routinely used in nearly every hospital in the US even in rural and outlying areas; the technology is there, we just need to use it.

Continuous Monitoring is Proven to Save Lives and Money

A study performed at the Dartmouth-Hitchcock Medical Center showed that clinicians using pulse oximetry and remote monitoring technologies to continuously monitor postoperative patients were able to identify signs of clinical distress earlier and improve outcomes.4,5

  • Monitoring reduced the number of Intensive Care Unit (ICU) interventions by 65% and days in the ICU by 135 per year.
  • The study showed savings of nearly $60,000 per patient equaling almost $1.5 million in annual savings for that single hospital.
  • Since implementing continuous monitoring in the hospital in 2007, no patients have died or had serious brain injuries as a result of respiratory depression from opioids.

Support for Continuous Monitoring

  • The Institute of Medicine described failure to rescue as a critical issue in healthcare quality.6
  • The Joint Commission has issued a Sentinel Event Alert, urging all hospitals to use continuous electronic monitoring for patients receiving post-operative opioids.
  • The Anesthesia Patient Safety Foundation recommends that all patients receiving parenteral opioids be continuously monitored.

Solve This Problem

  • Enact legislation that requires continuous monitoring using FDA approved pulse oximetry for adequacy of ventilation of all post-operative patients on opioids to reduce failure to rescue and save lives.



  1. The Joint Commission Sentinel Event Alert. Safe use of opioids in hospitals. 2012;49(8):1-5.
  2. Weinger MB and Lee, LA. “No Patient Shall Be Harmed By Opioid-Induced Respiratory Depression.” The Official Journal of the Anesthesia Patient Safety Foundation. Fall 2011.
  3. Reed K and May R. HealthGrades Patient Safety in American Hospitals Study. March 2011.
  4. Taenzer AH, Byke JB, McGrath SP and GT Blike. Impact of Pulse Oximetry Surveillance on Rescue Events and Intensive Care Unit Transfers: A Before-and-After Concurrence Study. Anesthesiology. 2010;112(2) 282-287.
  5. Taenzer AH and Blike GT. Postoperative Monitoring – The Dartmouth Experience. The Official Journal of the Anesthesia Patient Safety Foundation. Spring-Summer 2012.
  6. Committee on Quality of Health Care in America, Institute of Medicine, ed. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academy Press, 2001.