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Surveillance Monitoring for All

Posted By Administration, Tuesday, May 9, 2017

Breakout session at the upcoming NPSF Patient Safety Congress details an initiative to institute continuous surveillance monitoring on a large scale.

by Patricia McTiernan, MS

The Joint Commission’s 2012 Sentinel Event Alert #49 on the safe use of opioids in hospitals came as a wake-up call to many clinicians and leaders. Although opioids can be largely safe for many patients, the alert warned of dangerous potential side effects, particularly respiratory depression.

Just a few months after the release of that alert, an event related to respiratory depression and opioid analgesics resulted in a patient’s death at Wake Forest Baptist Medical Center in Winston-Salem, NC. A root cause analysis was conducted, and one of the recommended actions was to use surveillance monitoring of patients receiving opioids. That led to a major initiative resulting in widespread use of surveillance monitoring in multiple facilities.

Kristina Foard RN, MSNEd, SCRN, Nurse Practice Specialist, joined the effort to identify the best system for Wake Forest and assist with the implementation. She and Dr. Robert Weller, physician champion for the surveillance monitoring deployment and response to SE#49 at Wake Forest, were asked to evaluate some of the available bedside monitoring systems that would allow for surveillance monitoring.


Historically, medical/surgical nurses have relied on spot-checking their patients by collecting and recording vital signs every 4 to 8 hours. Of the opioid-related sentinel events reported to TJC between 2004 and 2011, 29% were related to improper monitoring of the patient. As early as 2011, the Anesthesia Patient Safety Foundation was calling for continuous electronic monitoring of oxygenation and ventilation in patients on opioids.

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Once the Wake Forest team had evaluated the options, they began a 20-week pilot program on a neurosurgery unit. Because they wanted to capture as much data as they could during the pilot, they decided that any bedded patient on that unit would be placed on continuous monitoring. At the end of the pilot period, they evaluated the data with the nursing staff and with patient and family input. When they presented the results to their leadership team, the decision was made to deploy surveillance monitoring broadly throughout their institution.
Karen Luse, MSN, Robert Weller, MD, and
Kristina Foard, RN, MSNEd, SCRN, of Wake
Forest Baptist Medical Center. Ms. Luse and
Ms. Foard will present a Breakout Session at the
upcoming NPSF Patient Safety Congress
about their organization's experience
instituting continuous monitoring


“One important lesson we learned by monitoring everyone is that risk stratification is extremely difficult,” said Ms. Foard. “We like to look at comorbidities and whether patients are opioid naïve or opioid tolerant, if they are obese or have Obstructive Sleep Apnea (OSA), because things like that put them at higher risk for opioid induced respiratory depression. But, in fact, many of the interventions triggered by continuous monitoring were not necessarily opioid-related. We also identified cardiovascular events including tachy- or bradydysrhythmias and hypo- or hypertension that we may have failed to identify if we hadn’t been doing surveillance monitoring on all patients.

“We elected then to apply surveillance monitoring as our standard of care. If you got bedded on a unit that had the monitoring, you were placed on monitoring and the provider had to write an order to remove you,” she added.

Some providers have asked for development of risk stratification that would allow for selective rather than surveillance monitoring of all patients, and this continues to be a barrier to overcome, Ms. Foard said. Both physicians and nurses commonly suggest that “young” and “healthy” patients did not need continuous monitoring, but an effective risk score to apply selective monitoring is not yet available.

Another challenge was alarm fatigue. The system cannot do the kind of critical thinking that nurses do, for example, so the team had to take care in setting wide enough parameters that would minimize non-actionable alarms without missing true deterioration events. These parameters were tested and optimized relative to alarm frequency. Ms. Foard and Dr. Weller also collaborated with their Rapid Response team to develop a flow chart to help the nursing staff manage and respond to alerts.

Ms. Foard and her co-presenter will discuss the technical challenges as well as the cultural challenges involved in such an initiative.

“Leadership support and buy-in from managers of the unit is an absolute must,” she said. “Without manager support, you’re not going to get the buy-in from the bedside nurses. Even beyond that, having the executive support for that cultural shift, especially a shift that impacts providers and nursing staff, is critical.”

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Kristina Foard and her co-presenter, Karen Luse, MSN, will talk about this initiative in Breakout Session 304: Surveillance Monitoring on General Care Floors, at the 19th Annual NPSF Patient Safety Congress. See details of the full Congress program.


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Patricia McTiernan is editor of the P.S. Blog. Contact her at

Tags:  2017 Patient Safety Congress  opioids  respiratory depression 

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Getting the Lowdown on Opioids

Posted By Administration, Friday, October 7, 2016
Updated: Friday, October 7, 2016

The nation’s opioid crisis was a hot topic at the 2016 NPSF Patient Safety Congress.

by Patricia McTiernan, MS


A recent survey conducted by the National Patient Safety Foundation showed gaps in health professionals’ knowledge regarding use of opioid painkillers. Only two-thirds of respondents were familiar with the Joint Commission Sentinel Event Alert on the Safe Use of Opioids in Hospitals, for example, and only 14% were familiar with the National Action Plan for Adverse Drug Event Prevention.


It may come as no surprise, then, that one of the most well-attended breakout sessions at the NPSF Patient Safety Congress in May focused on “DEA Drug Trends.” Thomas Prevoznik, liaison unit chief for the U.S. Drug Enforcement Administration, addressed some of the current questions health professionals have about what they can do to mitigate unintended harm from opioids.


According to the Centers for Disease Control and Prevention, opioid prescription painkillers led to more than 19,000 overdose deaths in 2014. Moreover, the DEA reports that 8 out of 10 new heroin users began by abusing prescription painkillers.


At the NPSF Congress, attendees were most interested in learning about proper disposal of unused or unwanted pharmaceuticals and how the DEA and health care professionals can work together to combat the opioid epidemic to ensure public health and safety.


The DEA is in the process of conducting Pharmacy Diversion Awareness Conferences at the state level to educate health professionals about tactics they can use to minimize unintended outcomes. These events include speakers from the state’s pharmacy board, the police, the Department of Health and Human Services, and the DEA.


  Thomas Prevoznik

Thomas Prevoznik speaking at the 2016  

NPSF Patient Safety Congress

Mr. Prevoznik says the events offer an opportunity to provide practical tactics to pharmacists and clinicians, for example:


  • Asking patients if they have a place to keep the prescription opioid painkillers under lock and key.
  • Asking clinicians to be more aware of the opioid epidemic and more conscious of the unintended effects of overprescribing.

Disposing of unused medications is another effort under way. Twice each year, the DEA, in collaboration with state and local law enforcement, sponsors National Prescription Drug Take-Back Day, an opportunity for people to clean out their medicine cabinets and safely dispose of unused medication. The last event was held in late April of this year, yielding almost 900,000 pounds of drugs—the highest amount collected since these events began in 2010.


“People are getting the message that they don’t need to save that just-in-case bottle,” Mr. Prevoznik says. “It’s better to get rid of it.”


The next Prescription Drug Take-Back Day is scheduled for October 22. Get details at


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About the Author: Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at



Tags:  2016 NPSF Congress  opioids 

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