Root Cause

Only 3 Countries Remain with Endemic Polio

By ThinkReliability Staff

Polio is a horrible, crippling disease.  According to the World Health Organization (WHO), of the children who contract polio, 1 of 200 will be irreversibly paralyzed.  Of the children who are paralyzed, 5 to 10% will die because their breathing muscles are paralyzed.  The Global Polio Eradication Initiative was formed in 1988.  That year, more than 350,000 people were paralyzed.  So far in 2012 only 181 cases have been reported.  Obviously this is a huge success, but unfortunately, it’s not quite enough.  As Centers for Disease Control & Prevention (CDC) Director Dr. Frieden states “If we fail to get over the finish line, we will need to continue expensive control measures for the indefinite future…More importantly, without eradication, a resurgence of polio could paralyze more than 200,000 children worldwide every year within a decade.”

Because polio cannot live outside the body for long periods of time (unlike most diseases) it can be eradicated.  The only human disease that has been completely eradicated is smallpox.

On February 25, 2012, India was removed from the list of endemic countries, leaving only three countries where polio is endemic: Afghanistan, Nigeria and Pakistan.  Eradication in these countries continues to be difficult for various reasons.  We can look at some of the causes of why eradication has been difficult in these countries and ongoing solutions to these difficulties by analyzing the issue in a Cause Map, a visual form of Root Cause Analysis.

We begin with the impacts to the goals.  Public safety is impacted because of the risk of death and paralysis.  Public services are impacted due to the risk of contracting polio.  Additionally, the compliance goal is impacted because children are not receiving full vaccinations against polio.

There are myriad reasons for children not receiving full immune protection from vaccination against polio.  First is the difficulty finding and accessing children.  Many children in endemic areas are nomadic or homeless.  The use of “transit teams” – vaccination teams stationed at transportation stations and large crossings – aims to increase vaccination of these children.  Children are marked after they receive vaccines, to ensure the vaccines are not repeated and to allow tracking of the success of the program.  In many of the endemic areas, children are inaccessible to vaccination teams due to conflict or violence in these areas.  In some areas vaccination teams are blocked by local governments or even subject to violence.  Some religious and local government leaders do not support the vaccination program, or the makeup of the vaccination teams.  Outreach campaigns aim to reach the public, community and religious leaders.  The GPEI, WHO and CDC are trying to work with governments and religious organizations to increase acceptance of the vaccines.  The creation of small scale immediate immunization response strategies aims to allow fast response when a previously inaccessible area becomes accessible, to maximize immunization during that time.

Some parents will not allow their children to be vaccinated.  In many cultures, women will not open the door to men.  Vaccination teams will generally include at least one woman to help increase acceptance from parents.  Parents are also reluctant to vaccinate newborns, or children who are sick or sleeping.  The importance of vaccinating these children is being added to outreach information and polio hotlines are being created to attempt to provide information to reluctant parents.  Because at least four doses of the polio vaccine are required to fully protect against the disease, these issues are magnified.  Permanent polio teams in the endemic areas aim to maximize the immunization coverage and attempt to eradicate this disease once and for all.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

NYC Hospital Unexpectedly Evacuated During Sandy

By Kim Smiley

On October 30, 2012, power outages forced evacuation of a New York City hospital amidst the onslaught of Hurricane Sandy.   All 217 patients in the hospital to had moved, including 20 infants staying in the neonatal intensive care unit.

This incident can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis.  The first step in the process is to fill in an Outline that lays out the basic background information and also identifies the impact to the goals.  In this example, the safety goal is clearly impacted because it is risky to evacuate patients during a hurricane.  Although the potential for injury was very real, no one was hurt during the evacuation and the hospital staff did an amazing job of carrying patients down darkened stairwells and ensuring basic life support remained stable.  The customer service goal is also worth considering since the unexpected evacuation received a large amount of negative publicity.

After the Outline is completed, the next step is to ask “why” questions to add Causes to the Cause Map.  Why were patients at risk?  This occurred because the hospital had to be evacuated because it lost power and the backup power generators failed.  Why the generators failed hasn’t been identified yet, but there is speculation that the age of the equipment may have played a role. It’s also possible that the location of the generators might be factor since a number of hospital building were flooded by ten feet of water.  Electrical service was lost because New York City was hit hard by Hurricane Sandy and saw unprecedented flooding and strong winds.  This wasn’t an unexpected impact of the storm, but the hospital did not expect the generators to fail, especially so quickly.  The patients were also at risk because the hospital had many patients in critical care units that required life support systems and the patients were evacuated under dangerous conditions, both inside and outside the hospital.  At the time of the evacuation the hospital had lost power and patients were being carried down stairs lit by flashlights.  Some patients were bought down 16 flights of stairs.  The evacuation also occurred during the hurricane so the conditions during the drive to a new faculty were potentially dangerous.  The evacuation occurred during the hurricane, as opposed to before the storm hit, because the hospital assured the city that it was prepared and could ride out the hurricane.

This issue is still being investigated, but once all the facts are known solutions can be developed and implemented to help ensure that patients aren’t forced to evacuate under similar adverse conditions.

Click on “Download PDF” above to see a high level Cause Map of this issue.

Root Cause

Update: Contaminated Injections Have Now Killed 29

By ThinkReliability Staff

In a previous blog, we discussed deaths related to fungal meningitis believed to have resulted from fungal contamination of a compounded drug used as an injection for back pain.  Sadly, since our last post, the numbers of deaths and injuries has risen.  So far, 29 patients have been killed and more than 360 have been sickened by the infected injections.  Because drugs from the three affected lots were injected for pain relief to approximately 14,000 patients, investigators expect to see many more cases in the coming months.  Some of these patients received injections in other joints, so they are suffering from peripheral joint infection, which is less severe and less likely to lead to death than fungal meningitis.

We can update the Cause Map, or visual root cause analysis, which was started in our previous blog.  Specifically, as investigators are able to provide more detail about the case, we can update causes and validate them with evidence.  We are also able to update the outline as more patient deaths and sickness are discovered.

Investigators have verified that the source of the fungal contamination was the compounding company.  They noted in investigations that the clean room was contaminated due to lack of control of the humidity and temperature.  It appears that the air conditioning was shut down at night, resulting in environmental issues. Additionally, sterilization at the company was found to be inadequate.  Sterilization procedures were not followed, and sterilization equipment was found to be contaminated, possibly because it was not properly tested.  Once the contamination made it into the drug, the drug was shipped without the company knowing of the contamination, because shipping on some lots took place before the results of sterility testing were received.

The Massachusetts Department of Health has announced increased oversight of compounding companies, including annual inspections.  A bill has been introduced in Congress for FDA regulation of compounding companies that produce larger quantities of drugs for mass distribution, as appears to be the case in this instance.  It also recommends requiring compounded drugs to contain a label stating they have not been FDA-approved.  Although the compounding company responsible for the contamination has been closed down, it is hoped that a higher level of regulation will reduce the possibility of similar deaths in the future.

To view the updated Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

Manifestation of Poor Glycemic Control Part 3

By ThinkReliability Staff

In previous blogs, we wrote about nonketotic hyperosmolar coma and diabetic ketoacidosis, which are both conditions related to hyperglycemia, or high blood glucose.  In this blog, we consider the last type of manifestation of poor glycemic control that, when it occurs in the hospital, is considered a hospital-acquired condition by Medicare & Medicaid, meaning that hospitals will not receive additional payment for cases when this condition is acquired during hospitalization.  Hypogelycemic coma, along with nonketotic hyperosmolar coma and diabetic ketoacidosis, results from poor glycemic control within the hospital, but is caused by low blood glucose.

As we did with the other two manifestations of poor glycemic control, we can look at the impacted goals for a hospital and the potential causes and solutions for this condition in a visual root cause analysis or Cause Map.  The goals for hypoglycemic coma are the same to the other manifestations of poor glycemic control and include increased risk of patient death, length of patient stay and treatment needs.  The costs associated with hypoglycemic coma (greater than $7 million in the US from the 212 cases reported to CMS in 2007) are no longer reimbursable when the condition is acquired in the hospital.  There is also always the potential that a patient death can result in a second victim – the patient’s provider(s).

Hypoglycemic coma results from uncontrolled hypoglycemia, which can result from overtreatment with insulin, drug-induced hypoglycemia, drug interaction with insulin, decreased glucose production and/or loss of glucose.  Overtreatment with insulin was implicated in 90% of hypoglycemia cases in a recent study and can result from medication errors (see our analysis on medication errors in hospital settings),  or a failure to adjust insulin for diet or other factors.  Drug-induced hypoglycemia can result from administration of fluoroquinolones (the mechanism for this effect is unknown) and/or inadequate nutrition.  Drugs that interact with insulin may be administered to a diabetic patient if providers are lacking in knowledge about glycemic control.  Underlying disease or infection, such as chronic renal insufficiency, which was implicated in approximately 50% of hypoglycemia cases in the study, can result in decreased glucose production or loss of glucose.

As with the other types of manifestations of poor glycemic control, efforts must be made to prevent these types of incidents.  As suggested with hyperglycemic events, insulin plans should be individualized, accounting for all relevant factors related to glycemic control and diet.  Patients treated with insulin in the hospital should have their blood glucose levels monitored frequently, especially as insulin has been identified as a High-alert medication by The Joint Commission.   Any patients found unconscious should also immediately have their blood glucose levels measured.  Patient’s nutritional intake must be carefully monitored, especially for cases involving medications that might cause hypoglycemia.  Last but not least, controls and procedures involving drugs given to diabetic patients should be carefully controlled, due to the high potential and risk for interaction with insulin.

Two other conditions are considered hospital-acquired manifestations of poor glycemic control: nonketotic hyperosmolar coma and diabetic ketoacidosis.   In previous blogs, we discussed the causes of these issues, and suggested solutions to reduce the risk of these types of incidents.

To view the Outline, Cause Map, and Potential Solutions, please click “Download PDF” above.  Or click here to read more.

Root Cause

Manifestation of Poor Glycemic Control Part 2

By ThinkReliability Staff

In a previous blog, we discussed how poor glycemic control can result in hyperglycemia which could lead to nonketotic hyperosmolar coma.  Diabetic ketoacidosis, if resulting from poor glycemic control within a hospital setting, is another hospital-acquired condition as determined by Medicare & Medicaid, meaning that hospitals will not receive additional payment for cases when this condition is acquired during hospitalization.  Like nonketotic hyperosmolar coma, diabetic ketoacidosis can have a significant impact on patient safety and can be investigated within a Cause Map, or a visual root cause analysis.

The impacted goals for a hospital resulting from hospital-acquired diabetic ketoacidosis are very similar to those for nonketotic hyperosmolar coma.  Patient safety is impacted due to an increased risk of death, which can also result in a provider being a “second victim.  This is a “no-pay” hospital acquired condition, which is estimated to cost $42,974 per case.  According to the Centers for Medicare & Medicaid Services (CMS), in 2007 there were 11,469 cases of hospital-acquired diabetic ketoacidosis, resulting in a total cost to the healthcare system of almost half a billion dollars.

According to a study  published in the International Journal for Quality in Health Care, diabetic emergencies, including nonketotic hyperosmolar coma,  increases the risk of patient death (from 9% to 16%),  length of patient stay (from 7 to 14 days) and treatment requirements.  The costs associated with nonketotic hyperosmolar coma (greater than $114 million in the US in 2007, according to CMS) are no longer reimbursable when the condition is acquired in the hospital.  Additionally, patient death due to hospital-acquired conditions can result in a second   victim – the healthcare provider(s).  Additionally, this diagnosis results in increased stay and treatment requirements.

Beginning with the impacted goals and asking “Why” questions, we quickly determine that diabetic ketoacidosis, like nonketotic hyperosmolar coma, results from uncontrolled hyperglycemia.  Rather than perform the same analysis of causes of hyperglycemia (which, if we’re doing our job right, should result in the same cause-and-effect relationships), we can link to the analysis shown in our previous blog.   However, for diabetic ketoacidosis, we also have a cause of dehydration.  Since this was not a cause previously analyzed, we will add to this portion of the Cause Map.

Patient dehydration can result from a medication that increases fluid loss, an underlying medical condition, or inadequate water intake.  Inadequate water intake can result from a patient’s limited access to water, such as a patient who is bedridden and is not provided adequate water from a caregiver, or the patient feels too ill to drink, or the patient is unable to drink, due to incapacitation, confusion, restraints or sedation.  A combination of these causes may also occur.

Because of the importance of preventing these conditions resulting from hyperglycemia and dehydration, every effort should be made to prevent these outcomes from occurring.

Two other conditions are considered hospital-acquired manifestations of poor glycemic control, diabetic ketoacidosis and hypoglycemic coma.  In future blogs, we will discuss the causes of these issues, and suggested solutions to reduce the risk of these types of incidents.  It is recommended that an individualized insulin plan be used, rather than a sliding scale, to ensure blood glucose levels are kept at or below 110 mg/dL.  A specific glycemic management team, which carefully coordinates medical nutritional therapy with insulin control, can also reduce the risk of glycemic events.  Patients who are found to have an insulin deficiency should be treated with intravenous insulin.

Because 20-30% of diabetic ketoacidosis cases are estimated to be the initial presentation of previously undiagnosed diabetes, some experts recommend testing the glucose levels of all children who have not been diagnosed with diabetes, and all patients who are vomiting or require intravenous hydration.  To reduce the risk of dehydration, patient’s fluid intake should be tracked and any patients who are unable to  drink should have intravenous fluids.

Nonketotic hyperosmolar coma and diabetic ketoacidosis are two hospital-acquired events that result from hyperglycemia.  The remaining hospital-acquired manifestation of poor glycemic control, hypoglycemic coma, will be covered in a future blog.

To view the Outline, Cause Map, and Solutions please click “Download PDF” above.  Or click here to read our previous blog.

Root Cause

Manifestation of Poor Glycemic Control Part 1

By ThinkReliability Staff

Nonketotic hyperosmolar coma resulting from poor glycemic control within a hospital setting is now considered a hospital-acquired condition by Medicare & Medicaid, meaning that hospitals will not receive additional  payment for cases when this condition is acquired during hospitalization.  Because of the severity of the impact of this condition, its implications and causes should be carefully studied to determine ways to reduce the risk of this condition being acquired during a hospital stay.

We can look at the impacted goals for a hospital and the potential causes for this condition, in a visual root cause analysis or Cause Map.  To perform a Cause Mapping analysis, we will first determine the impacts of a given condition on an organization’s goals, then develop cause-and-effect relationships to diagram the causes that result in the condition.

According to a study published in the International Journal for Quality in Health Care, diabetic emergencies, including nonketotic hyperosmolar coma,  increases the risk of patient death (from 9% to 16%),  length of patient stay (from 7 to 14 days) and treatment requirements.  The costs associated with nonketotic hyperosmolar coma (greater than $114 million in the US in 2007, according to CMS) are no longer reimbursable when the condition is acquired in the hospital.  Additionally, patient death due to hospital-acquired conditions can result in a second victim – the healthcare provider(s).

To analyze this issue, we begin with an impacted goal and ask “Why” questions.  In this case, we are looking at the impact to the patient safety goal becaue of the  increased risk of patient death due to nonketotic hyperosmolar coma, which is caused by uncontrolled hyperglycemia (high blood glucose).   Associated infection, medication that interferes with glucose absorption, and insulin deficiency can all contribute to hyperglycemia.  Insufficient knowledge of providers about glycemic control can result in diabetic patients being given medications that interfere with glucose absorption, or in inadequate control of diabetes with insulin in the hospital setting.

The study referenced above also found that insufficient staffing, which may result in insufficient backups/checks of staff, use of workarounds, and ineffective communication between the team, leading to insufficient tracking of glycemic control.    Providers may also be unaware of a patient’s diabetic status, due to poor record keeping or communication.   Inadequate insulin therapy can also contribute to hyperglycemia.  Specifically, medication errors involving insulin (see our medication error Cause Map), fear of hypoglycemia (which may result in fear of aggressive insulin therapy), and  failure to adjust insulin for diet or other factors, including age, renal failure, liver disease, can result in an all too common “one size fits all” linear sliding insulin scale providing inadequate results.

Two other conditions are considered hospital-acquired manifestations of poor glycemic control, diabetic ketoacidosis and hypoglycemic coma.  In future blogs, we will discuss the causes of these issues, and suggested solutions to reduce the risk of these types of incidents.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

Contaminated Injections Kill 5

By ThinkReliability Staff

At least 35 patients have come down with rare fungal meningitis after an injection they received for back pain was contaminated with fungus. Five have died so far. Because of the severity of the disease and the long incubation period, more cases – and more deaths – are expected in the coming months.

We can examine the issues related to the fungal meningitis in a Cause Map, or visual root cause analysis. Documenting the causes visually can make a complex medical issue easier to understand. We begin with the impacts to the goals. The deaths and severe sickness are an impact to the patient safety goal. While we begin with the known cases, these numbers can be updated if more cases are discovered. The compounding company which prepared the injections has voluntarily surrendered its license, an impact to the compliance goal and has recalled 3 lots of the drug used in the injection (methylprednisolone acetate), which can be considered an impact to both the organizational and property goal. The extremely difficult treatment ahead of these patients (estimated to take months) is an impact to the patient services and labor goal. The contamination of the injection itself can be considered an environmental goal.

Once we have captured these impacted goals, we can begin with the focus of our investigation – the patient safety goal – and ask “why” questions to develop the cause-and-effect relationships that resulted in the disease. The patient deaths and sickness are due to contraction of fungal meningitis. These patients came down with fungal meningitis because fungus was introduced to their nervous system. The injections that the patients received for back pain were injected epidurally, which allows access to the nervous system, and were infected with aspergillus, a common fungi. More testing is being done to determine whether the contamination was in the drug within the injection, or the numbing agent or antiseptic wipes being used. Due to the widespread (across several states) outbreak, it is believed that the drug within the injection is to blame, but because of the seriousness of this issue, all potential causes are being carefully tested.

Because the drug used in the injection was compounded, the contamination could have occurred within a raw ingredient used in the compounding, or it could have become contaminated during the compounding process. The source of the outbreak is not yet known, but because compounded drugs and compounding companies receive less oversight than drug manufacturers, it is suspected that the contaminant was introduced during the compounding process.

Initial symptoms of fungal meningitis are subtle, including headache, fever, dizziness, nausea and slurred speech. The symptoms can take up to a month from introduction of the fungus to appear. If patients have received a shot for back pain, they should contact their doctor to see if it was from the infected lot. Early and immediate treatment is important.

To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more.

 

Root Cause

More Known About Why A Donated Kidney Was Trashed

By ThinkReliability Staff

In a previous blog, we wrote about a donated kidney that was accidentally thrown out rather than being transplanted.  We began the root cause analysis investigation with the information that was available, but there were still a lot of open questions.

The Centers for Medicare & Medicaid Services (CMS) has released a report on the incident, which provides additional information we can use to update our Cause Map.  We can update all areas of the investigation, including updating any additional goals that were found to be impacted.  In this case, three employees had been placed on administrative leave.  Since the time of the previous blog, four employees have had their careers impacted – one has resigned, one has been fired, one has had a title removed, and another has since returned from paid administrative leave.  Additionally, there is a risk that the hospital may be removed from the Medicare program, another impact to the compliance goal.

The report provides more specific causes, and evidence, regarding the incident.  We know now that the kidney, which was to be transplanted, was instead thrown in a hopper by the circulating nurse.  We can ask “Why” questions to add more detail.  The kidney was thrown in the hopper because the contents of the slush machine were thrown in the hopper and the kidney was in the slush machine.  It still isn’t clear why the kidney was in the slush machine in the donor’s operating room (rather than being transferred immediately to the recipient’s room), but more information regarding the disposal is now available.

The nurse disposed of the hopper because she was unaware that  the slush machine contained the kidney.  The nurse had been on lunch break when the location of the kidney was announced and was not briefed on the status of the operation upon her return.  There was no documentation on where the kidney was located, and the nurse assumed that it was in the recipient’s room.  For reasons that are unclear (as it is usually the job of the technician who is responsible for the machine), the nurse decided to empty the slush machine while the operation was still ongoing.  This appeared to be against procedure, but the procedure had “exceptions” according to staff, and was ineffective in this case.  The technician that was responsible for the slush machine was exerting inadequate control, as the staff members have stated that no one noticed the nurse empting the slush machine.  This also demonstrates inadequate control of the kidney, since there appeared to be no staff person responsible for the kidney itself.

Since the incident, the hospital has developed a procedure for intra-operative hand-off, which includes a briefing requirement for staff members who enter an operating room mid-procedure.  Additionally, clarification has been provided that nothing will leave an operating room until the patient has left, post-procedure.  Although the transplant program is still shutdown pending investigation, a recommendation that might reduce this type of problem in the future would be to ensure that a staff member is designated as responsible for any donated organs from removal to transplant.

To view the updated Cause Map and potential solutions, please click “Download PDF” above

Root Cause Analysis

Teen Impersonates a Physician’s Assistant

By Kim Smiley

A teen, who was 17 at the time, was arrested on September 2, 2012 for impersonating a physician’s assistant in a Florida hospital.  The young man worked at a hospital, treating patients and performing duties typical of a physician’s assistant, for about a week before anyone became suspicious of his lack of credentials.  Investigation into the case found that he examined patients, removed an IV and even performed CPR without any medical training.

How could this possibly happen?  A Cause Map, or visual root cause analysis, of this situation can be built to help understand the different causes that contributed to a young man successful impersonating a medical professional.  The first step in building a Cause Map is to determine how the issue impacted the overall organization goals.  In this example, the safety goal is clearly impacted since an unlicensed individual treated patients.  The customer service goal was also impacted because of the negative publicity for the hospital involved in the scandal.

Causes are added to the Cause Map by asking “why” questions.  Why did this happen?  How did a teen end up performing the duties of a physician’s assistant?  Statements by the teen indicated that he was interested in learning more about the profession so he decided to work at the hospital.  He was able to pull this off because he was incorrectly given a physician’s assistant identification badge and nobody initially questioned his credentials because he acted the part well.

The teen worked as a clerk in a doctor’s office near the hospital and when he went to the ID office to get a badge, he was somehow given the wrong one.  His credentials were never checked and personnel at the ID office have stated that this was because the office was very busy at the time.  The teen also never told anybody he had the wrong badge and decided to use it.

The masquerade was also successful for a time because the teen played the role of physician’s assistant well.  He wore scrubs and a stethoscope and used the correct terminology.

This case went to trial in August 2012.  The teen was found guilty on two counts of impersonating a physician assistant and two counts of practicing medicine without a license.  His sentencing is scheduled for November 14 and he faces up to 25 years in prisons.

To view a high level Cause Map, click “Download PDF” above.

Root Cause Analysis

Safe Use of Opioids in Inpatient Hospitals

By ThinkReliability Staff

The use of opioids for pain relief in inpatient hospitals can lead to serious potential adverse effects, including respiratory depression and drug interaction.  On August 8, 2012, The Joint Commission published a Sentinel Event Alert: “Safe use of opioids in hospitals”.  The alert contains information about potential causes of the adverse effects possible with the use of opioids as well as solutions that, if implemented by healthcare facilities, can reduce the risk of patient safety impacts from the use of opioids.

We can present the information provided by The Joint Commission in a Cause Map, or visual root cause analysis.  We begin with the impacts to the goals.  In this case, we look specifically at two potential impacts to the patient safety goal – the risk of drug-drug interactions and respiratory depression involving opioids.

Drug-drug interactions can result when a patient is taking another drug that interacts with opioids. In this case, the provider prescribing the opioid is unaware of the potential interaction between the drugs prescribed or is unaware of the patient’s drug history, because a complete history is unavailable and a patient is either unable or unwilling to provide a compete list. While drug-drug interactions are possible with any level of opioid, the over-use of opioids for pain relief is a particular concern.  Opioids can be effectively used for pain relief, but over-use can occur when a high dose is needed to manage pain, either due to tolerance from chronic conditions or patient abuse, or obesity.  Studies have shown that obese patients may require more opioids for pain relief than would be suggested by their weight alone.  A patient receiving the wrong dose of opioids (besides being an issue in itself) can also contribute.  Issues have been raised regarding the difficulty in calculating doses with drugs of different potency, especially as patients move from one drug to another.  Additionally, prescribing dose based on weight alone can result in a higher or lower dose than needed as the proper dose of opioids is subject to patient weight, age, sex, and tolerance level.

Issues with prescribing the wrong dose or wrong type of medication can occur when a patient or family member is responsible for the administration.  Problems with medication administered by a provider typically occur around changes of the type or delivery method of the pain killer.  Special care should be taken to recalculate the dose  corresponding to any change in the drug dosage, type or delivery method.  Similar-looking bottles and similar-sounding names are always a potential pitfall in proper drug administration and special care should always be taken in these cases.

Opioids reduce respiratory rate, which can result in respiratory depression.  Respiratory depression can be impacted by other factors, such as a patient who is sleeping (most respiratory depression occurs during typical sleeping hours), or who is already pre-disposed to respiratory depression.  This most commonly occurs with post-surgical patients (who may have residual anesthesia), old or young patients (who may be affected more greatly by the respiratory effects), patients who have abnormal respiratory control due to obstructive sleep apnea or morbid obesity, patients with supplemental oxygen and patients who have a self-administered drug delivery system, such as a fentanyl patch.  Special care and monitoring should be taken with patients who have a higher risk level for respiratory depression.

However, monitoring for respiratory depression is difficult.  Visually assessing respiratory depression (especially while a patient is sleeping or on supplemental oxygen) is extremely difficult.  Using pulse oximetry can result in misleading values (including normal values while a patient is suffering from respiratory depression) and high false alarms.  Because respiratory depression occurs gradually, intermittent monitoring may not be sufficient to pick up on a patient’s decline.

There is no one-size-fits-all solution for reducing respiratory depression.  Rather, an individualized plan based on patient pain requirements and risk factors is shown to be the recommended way to reduce the risk of respiratory depression and ensure proper pain control for patients.

To view the Cause Map and recommended solutions, please click “Download PDF” above.  Or learn more from The Joint Commission Sentinel Event Alert.