Patient Safety Success Story

 Published: December 12, 2018

By: Heather Willden


image of RT holding hand of a patient

Baylor University Medical Center dramatically reduces instances of Failure to Rescue: Opioid-Induced Respiratory Depression

Article courtesy of the Patient Safety Movement Foundation

Failure to identify and treat opioid-induced respiratory depression is unfortunately common with stories of patients found “dead in bed” in the hospital. That was the case for 12-year-old Leah Coufal. After undergoing successful elective surgery at a prestigious Southern California hospital, Leah was found dead in bed by her mother who was at her side but drifted to sleep, awaking only to find that her daughter had passed. Leah was a victim of undetected respiratory arrest, caused by the narcotics that were intended to ease her pain.1

Sadly, Leah isn’t alone.

In June 2009, Baylor University Medical Center recognized that they had also had a growing problem and were routinely seeing more than 40 Rapid Response Team calls on one floor each month due to opioid-induced respiratory depression. The process Baylor University Medical Center developed forms the basis for the Patient Safety Movement Foundation’s Actionable Patient Safety Solutions (APSS) on Failure to Rescue: Opioid-Induced Respiratory Depression.

photo of michael a e ramsay
Dr. Michael A.E. Ramsay, MD, FRCA Chairman, Department of Anesthesiology and Pain Management at Baylor University Medical Center

“We had some really bad situations regarding “near misses” and that was unacceptable. So we created the Breathe Team and brought together everyone involved in the care of the patient. This included doctors, nurses, physicians and patient advocates,” recalled Dr. Michael A.E. Ramsay, MD, FRCA Chairman, Department of Anesthesiology and Pain Management at Baylor University Medical Center.

The Breathe Team met weekly and looked at the causation for each failure to rescue event including what happened, what could be done to prevent these events. They examined each case from opioid-induced respiratory depression with the same scrutiny and methodology of a plane crash.

“It’s time-consuming, but you have to do it. At first, we examined whether we could identify predictors of who would be sensitive to opioids. For example, were overweight people more sensitive? But what we found was that you couldn’t predict opioid sensitivity. Anyone could be sensitive to opioid arrest,” explained Dr. Ramsay.

A respiratory therapist on the team asked the question: “Why is it all the patients who developed severe respiratory depression were on nasal oxygen?” We looked at it and discussed with our recovery room nurses as all these patients had normal pulmonary function. It turned out that when the oxygen was discontinued in the PACU the patient’s oxygen saturation fell below normal so the oxygen was reapplied so that the patient could be discharged to the floor in a timely fashion. We then realized that this was respiratory depression from the opioids received and the patients needed to breathe more deeply and stay in PACU a little longer until they could maintain their oxygen saturation. The oxygen was masking the respiratory depression, so we put in place an oxygen withdrawal trial for all patients with normal lung function before leaving PACU, thanks to a very astute respiratory therapist.

As a result, the Breathe Team was able to identify specific process improvements for the hospital and educate staff. The Baylor Breathe Improvements included:

  • Standardized post-operative opioid (PCA) order sets. Over 50 different sets existed previously.
  • Stopped continuous PCA in opioid naïve patients
  • Instituted the “Oxygen Withdrawal Trial” in PACU – a test for respiratory depression.
  • Screened pre-operatively for patients at increased risk for respiratory depression and applied a blueberry wristband

Among the new standardized protocols included continuously monitoring all patients.

“It’s not standard practice in hospitals to put people on monitors, but people are now beginning to understand how dangerous these drugs are, and non-invasive monitoring technology is now becoming commonplace. It reached the stage where we can monitor continuously and unobtrusively, all patients and be alerted when they are getting into trouble,” explained Dr. Ramsay. “It is using similar technology that more and more people are using every day to monitor heart rate, steps walked, calories burned.”

As a result of the changes, Baylor University Medical Center went from 40 monthly rapid response team activations a month to three, and these are early calls. Due to the continuous monitoring of patients, the staff is warned early enough to identify and treat patients, preventing costly return to ICU stays. It has saved the hospital money and more importantly kept patients safe.

Baylor University Medical Center’s success in addressing Failure to Rescue formed the basis for the Patient Safety Movement’s APSS. And given the diligence the hospital used to address Failure to Rescue, it is no surprise that they have used resources, including the APSS, to address other areas to improve patient safety.

“The APSS are written as a recipe. You can get all the other hospital staff involved; you can adjust the APSS and make them work for the individual challenges a hospital is facing, Patient safety is a team effort,” Dr. Ramsay said.

The Patient Safety Movement will hold the 7th Annual World Patient Safety, Science & Technology Summit in Huntington Beach, California on January 18-19, 2019. The Summit will explore the leading causes of preventable in-hospital patient deaths as well as new topics such as Delirium, Hospital Transparency of Preventable Patient Deaths from legal and policy perspectives and more. For more information, visit



1 Patient Safety Movement Foundation (2014) Leah Coufal’s Story. Retrieved from website:

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Heather Willden

Heather Willden is the Director of Governance and Strategic Initiatives for the AARC where she works with state affiliates as the HOD liaison. She also manages DEI efforts and strategic initiatives. Connect with her about these topics by email, AARConnect or LinkedIn. When she's not working, you can find her podcasting with her husband, exploring new hiking trails, photographing, and spending time with her family.

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