“Nurses in intensive care units stated that the primary problem with alarms is that they are continuously going off and that the largest contributor to the number of false alarms in intensive care units is the pulse oximetry alarm. A ‘smart alarm’ that analyzed multiple parameters, like oxygenation and adequacy of ventilation, in a patient’s condition, may be a solution. This would increase patient safety by making it easier for nurses to assess a patient’s condition and reduce the frequency of false alarms.”

Maria Cvach, RN, MSN, CCRN, Assistant Director of Nursing and Clinical Standards at The Johns Hopkins Hospital (on smart alarms)

“One reason why it is not effective is that a ‘periodic check’ and pulse oximetry would only catch an error, not prevent the error.”

Matthew Grissinger, Director, Error Reporting Programs at Institute for Safe Medication Practices

“As a practicing anesthesiologist, I believe that spot-checking oxygen saturation is not sufficient.”

Elana B. Lubit, NYU School of Medicine

“Monitoring only SPO2 does not assess adequacy of oxygenation, especially in patients receiving oxygen post op. Also, check q 2.5 hours allow too long a time for hypoxic brain damage to occur…continuous monitoring of ETCO2 and respiratory rate must be added.”

E Frost, Icahn Medical Center at Mount Sinai

“The conclusions and recommendations of APSF are that intermittent ‘spot checks’ of oxygenation (pulse oximetry) and ventilation (nursing assessment) are not adequate for reliably recognizing clinically significant evolving drug-induced respiratory depression in the postoperative period. For the CMS measure to better ensure patient safety, APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients.”

Robert Stoelting, MD, President of the Anesthesia Patient Safety Foundation

“Spot checks of SpO2, as are commonly taken on med/surg floors, need to be eliminated from patient monitoring practice because these single measurements may mislead a provider into thinking the patient is fine when in fact they may be close to the precipice of unrecoverable respiratory depression. Entering a patient room and placing a pulse oximeter on their finger stimulates their consciousness and respiration sufficiently to falsely elevate their reading, particularly when they are receive supplemental oxygen. Once the provider leaves the room, this stimulus fades and the patient may lapse back into a dangerous level of respiratory narcosis.”

Dr. Frank Overdyk, Executive Director for Research, North American Partners in Anesthesiology, and Professor of Anesthesiology at Hofstra North Shore-LIJ School of Medicine

“One action that VHA has taken to address this high error incident rate is to use a PCA pump that has an integrated end tidal CO2 monitor or capnograph. A capnograph measures in real-time the adequacy of ventilation. Using this technology could prevent more than 60 percent of adverse events related to PCA pumps.

“In addition, we developed a standard protocol that looks at the other key issues that need to be addressed for safe use of PCA pumps: human factors (communication, training, fatigue and scheduling); the environment and equipment, rules, policies and procedures, and barriers and controls.”

Bryanne Patail, Biomedical Engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety

“We have a healthcare system that relies on the heroism of our clinicians rather than designing safe systems. There is technology right now that can monitor someone.”

Dr. Peter Pronovost, PhD, FCCM, Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient Care

“Monitoring patients for how much carbon dioxide they are breathing out with capnography provides us with the earliest possible indicator to detect the onset of opioid-induced respiratory depression. Continuously electronically monitoring with capnography will save lives.”

Dr. Cheryl Wibbens, Chief Medical Officer at Memorial Hospital

“For pregnant women, the risk of VTE is 4-5 times higher than women who are not pregnant. Moreover, this risk is at least twice as much following cesarean delivery.”

Dr. Andra James, Professor of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Virginia School of Medicine