“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.
- The Joint Commission Sentinel Event Alert. Safe use of opioids in hospitals. 2012;49(8):1-5.
- 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.
- Reed K and May R. HealthGrades Patient Safety in American Hospitals Study. March 2011.
- 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.
- Taenzer AH and Blike GT. Postoperative Monitoring – The Dartmouth Experience. The Official Journal of the Anesthesia Patient Safety Foundation. Spring-Summer 2012.
- 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.