2014 Summit Co-Convener:Founder:

Patient Safety Science & Technology Summit2014

2014 Summit Co-Convener:Founder:

Michael Ramsay, MD, FRCAChairman, Department of Anesthesiology, Baylor University Medical Center,President Baylor Research Institute

2014 Summit Co-Convener:Founder:

Failure to Rescue

2014 Summit Co-Convener:Founder:

Failure To Rescue• When a complication is not recognized in a timely manner or

treated appropriately– Many deaths and permanent disabilities could be avoided if:–Adopted safe practices

• Implemented systems that facilitate patient safety • Failure to Rescue is a measure of hospital quality• More dependent on the hospital characteristics than the

acuity of the patient– Jeffrey Silber 1992

2014 Summit Co-Convener:Founder:

Failure to Rescue Post-Operative Surgical Patients

• Opioid analgesics are associated with adverse effects and cause respiratory depression - 0.5% of post-surgical patients

• Opioid-related adverse drug events – including deaths –reported to The Joint Commission’s Sentinel Event database (2004-2011)

- 47% wrong dosing medication errors- 29% improper monitoring of the patient- 11% other factors including dosing, med interactions, adverse drug

reactions

2014 Summit Co-Convener:Founder:

2014 Summit Co-Convener:Founder:

2014 Summit Co-Convener:Founder:

APSF Recommendations (2011)• All patients should have oxygenation monitored by continuous pulse

oximetry (Patient Surveillance System)• Measure adequacy of ventilation when supplemental oxygen is

needed• Intermittent checks of oxygenation (oximetry) and ventilation

(nursing assessment) are inadequate• Assessment of consciousness/sedation is critical• Alarm fatigue and inadequacy of threshold-based alarms

2014 Summit Co-Convener:Founder:

Joint Commission Sentinel Event Alert (August 8, 2012)

Causes of adverse eventsLack of knowledge about potency

Improper prescribing/multiple opioidsInadequate monitoring

2014 Summit Co-Convener:Founder:

CMS Proposed Quality Measure #3040(2013)

• Calls for “appropriate monitoring of patients receiving PCA”• Defined as maximum period between documented respiratory rate,

sedation score and pulse oximetry does not exceed 2.5 hours• Intermittent monitoring would meet the minimum requirement• CMS received significant feedback that monitoring should be

continuous• Final determination not announced yet by CMS

2014 Summit Co-Convener:Founder:

The Baylor Breathe TeamMission: To eliminate patient harm from postoperative respiratory depression• Physicians• Nurses• Pharmacists• Administrators• Safety officers• Respiratory Therapists

2014 Summit Co-Convener:Founder:

2014 Summit Co-Convener:Founder:

Actions• Standardized post-operative opioid (PCA) order sets. Over

50 different sets existed.• Stopped continuous PCA in opioid naïve patients• Instituted the :Oxygen Withdrawal Trial” in PACU• Screened pre-operatively for patients at increased risk for

respiratory depression and applied blueberry wrist band

2014 Summit Co-Convener:Founder:

Considerations• Sedation precedes respiratory pauses. (Rising PaCO2)• Sedation drugs can potentiate respiratory depression. (esp.

phenergan, benadryl) • Avoid rapid dose escalation in opioid tolerant patients• Avoid using opioids to meet an arbitrary pain rating• Dosing should be based on individual’s need and condition• Take extra precautions when transferring between departments and

facilities• Deployment of continuous monitoring of respiration, oxygenation with

a closed loop notification

2014 Summit Co-Convener:Founder:

OUTCOMES

Orthopedic Surgical Floor 0.83 Rapid Response Team (RRT) Calls per Month

All Hospital: 8 RRT Calls per month reduced to 3.58

No Postoperative Respiratory Depression deaths

2014 Summit Co-Convener:Founder:

Failure to Rescue

Steven C. MoreauPresident & CEO,St. Joseph Hospital

Julianne Morath, MS, RNPresident & CEO, Hospital Quality Institute, California

J.P. Abenstein, MDASA President Elect, Division of Cardiovascular and Thoracic Anesthesiology, Associate Professor of Anesthesiology, Mayo College of Medicine, Rochester, MN

Dean Chittock, MDAssociate Professor of Medicine at the University of British Columbia

Andreas H. Taenzer, MD, MSAssociate Professor of Anesthesiology and Pediatrics, Director, Pediatric Acute Pain Service, Dartmouth-Hitchcock Medical Center, Director of the Dartmouth Patient Deterioration Prediction Laboratory (DP2L)

Susan Lorenz, DrNP, RN, NEC-BC, EDACVice President of Patient Care Services/Chief Nursing Officer, Princeton HealthCare System

Helen HaskellFounder of Mothers Against Medical Error

2014 Summit Co-Convener:Founder:

Failure to Rescue

2014 Summit Co-Convener:Founder:

Patient Safety Science & Technology Summit2014