Avoiding Adverse Events Secondary to Opioid-Induced Respiratory Depression: Implications for Nurse Executives and Patient Safety

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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.


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.


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.


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


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.

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