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Avoiding Adverse Events Secondary to Opioid-Induced Respiratory Depression

Implications for Nurse Executives and Patient Safety

Jungquist, Carla R. PhD, NP; Correll, Darin J. MD; Fleisher, Lee A. MD; Gross, Jeffrey MD; Gupta, Rajnish MD; Pasero, Chris MS, RN-BC; Stoelting, Robert MD; Polomano, Rosemary PhD, RN

JONA: The Journal of Nursing Administration: February 2016 - Volume 46 - Issue 2 - p 87–94
doi: 10.1097/NNA.0000000000000301

BACKGROUND: Guidelines with recommendations for monitoring type and timing of hospitalized patients for opioid-induced respiratory depression have been published, yet adverse events continue to occur.

OBJECTIVE: This study reports on the monitoring practices of 8 hospitals that volunteered to pilot test a Centers for Medicare & Medicaid Services e-quality measure that was under development. Recommendations for nurse executives are provided to support patient safety.

METHODS: Data on monitoring practices were collected retrospectively from the electronic medical records at 8 hospitals on all patients receiving intravenous (IV) opioids for more than 2.5 continuous hours via patient-controlled analgesia (PCA). Analysis included the percentage of patients who were monitored according to specific standards developed by a panel of technical experts with comparisons of naloxone use to monitoring practices.

RESULTS: Recommended patient assessments occurred in only 8.3% of the patients. No patients who were assessed at least every 2.5 hours received naloxone.

CONCLUSIONS: Care for patients receiving IV PCA is lacking in adherence to latest safety standards. Nurse executives must implement structures and processes to promote vigilance with evidence-based monitoring practices.

Author Affiliations: Assistant Professor (Dr Jungquist), School of Nursing, University at Buffalo, New York; Assistant Professor of Anaesthesia (Dr Correll), Harvard Medical School, Boston, Massachusetts; Professor and Chair (Dr Fleisher), Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia; Professor and Chairman (Dr Gross), Department of Anesthesiology, University of Connecticut School of Medicine, Farmington; Assistant Professor (Dr Gupta), Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee; Pain Management Clinical Consultant (Ms Pasero), El Dorado Hills, California; President (Dr Stoelting), Anesthesia Patient Safety Foundation, Indianapolis, Indiana; Professor of Pain Practice (Dr Polomano), University of Pennsylvania School of Nursing, Philadelphia.

Dr Stoelting is the president of the Anesthesia Patient Safety Foundation. The rest of the authors declare no conflicts of interest.

Correspondence: Dr Jungquist, School of Nursing, University at Buffalo, 3435 Main St, Wende 314, Buffalo, NY 14214 (

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