Near-Miss Data Show Signs of Trouble Outside OR

Anesthesiology News recently published an article “Near-Miss Data Show Signs of Trouble Outside OR“, which discusses the research conducted by Angela Lipshutz, MD, MPH (critical care fellow, University of California, San Francisco School of Medicine) and her colleagues.

Below is the letter to editors of Anesthesiology News from Michael Wong, executive director of the Physician-Patient Alliance for Health & Safety:

The recent article, “Near-Miss Data Show Signs of Trouble Outside OR” (March 2013, page 1) outlines the causative mechanisms associated with near misses in non–operating room situations. The increase in near misses underscores the necessity for increased safety measures.

As the provision of anesthesia outside the operating room increases in frequency, hospitals need to ensure safety strategies are extended beyond the operating room as well. In 2012, the Joint Commission issued Sentinel Event Alert 49 on safe use of opioids in hospitals, which underscores the association of adverse events with use of opioid analgesics. In particular, the Sentinel Event Alert highlights some of the causes for opioid-related adverse events: lack of knowledge about opioid potency, improper prescribing and administration, and inadequate patient monitoring.

These causative issues are consistent with many of the mechanisms uncovered by Dr. [Angela] Lipshutz and her team that indicate that the majority could be fixed by hospitals. However, more importantly, if these causes can be fixed, this leaves open the larger question of the liability of hospitals that know and do not fix. For example, in the Sentinel Event Alert, the Joint Commission cautioned against relying on pulse oximetry alone when it stated, “Staff should be educated not to rely upon pulse oximetry alone because pulse oximetry can suggest oxygen saturation in patients who are actively experiencing respiratory depression … .”

Clinicians need to monitor patients outside of the operating room for hypoxia and hypoventilation to mitigate the risk for respiratory arrest induced by opioid analgesics. In the checklist we recently released, which can be downloaded for free from our website (, one recommended step is to electronically monitor patients with both pulse oximetry and capnography.

Many of the causative mechanisms uncovered by Dr. Lipshutz and her colleagues are within the control of hospitals. Does this study and the Joint Commission’s Sentinel Event Alert put hospitals and anesthesiologists and other health care providers and staff who work in them on notice of the issues they should know and fix?

If it doesn’t, I think that it may certainly put lawyers, who represent patients harmed by opioid analgesics, on notice of what they should look for in and the standard of care they will be asking courts to measure health care providers against.

– Michael Wong, JD

Leave a Comment, if You Care About Patient Safety