# data[].attributes.headline
Intervention 1: Continuous Electronic Monitoring

# data[].attributes.subject
Intervention 1: Continuous Electronic Monitoring

# data[].attributes.body
Pulse oximetry: The percentage of oxygen in a patient’s bloodstream that is measured noninvasively

Capnography: monitors how effectively a person is breathing by measuring their exhaled carbon dioxide (typically through a nasal cannula)

Research shows that combining pulse oximetry with capnography results in better patient outcomes compared to using pulse oximetry alone (Vockley, 2013). These monitoring tools provide early warning signs of respiratory depression, especially in patients receiving opioid therapy via PCA pumps. When connected to PCA pumps, these systems can automatically pause opioid delivery if respiratory compromise is detected, adding an important layer of safety (Vockley, 2013).

EBP Intervention: Use continuous pulse oximetry and capnography for patients on opioids, especially via PCA.

Why: PCA-related respiratory depression is often not detected early

Impact: Early detection of hypoventilation and desaturation can prevent fatal events

A.M.

# data[].attributes.body
Failure of Hospital Policies to Protect Patient Safety

# data[].attributes.headline
Intervention 2: Intentional Nurse Rounding

# data[].attributes.subject
Intervention 2: Intentional Nurse Rounding

# data[].attributes.body
Lack of Nurse Rounding: A key safety error in this case was related to the lack of nurse rounding during night shift to assess the patient's condition. This resulted in Louise Batz having an ultimately fatal anoxic brain injury due to respiratory suppression from the combined medications she received.

EBP Intervention: Intentional rounding (IR) is structured, proactive nurse-patient interactions performed at regular intervals (hourly or every two hours), using the "4Ps" approach: Pain, Positioning, Personal needs, and Placement. IR enhances therapeutic communication, proactively identifies patient needs, and ensures delivery of fundamental nursing care (Al-Anati et al., 2024). The intervention standardizes bedside presence and safety checks, contributing to early identification of patient deterioration and improved patient experience.

Why: With hourly or even q2 rounding the nurse could have quickly detected the deterioration of Louise Batz's condition before it progressed to an anoxic brain injury.

Impact: Early detection of a patient's deteriorating status can prevent fatal outcomes and improve patient safety.

# data[].attributes.headline
Intervention 3: Overdose Reversal Agents 

# data[].attributes.subject
Intervention 3: Overdose Reversal Agents 

# data[].attributes.body
Missing Safety Materials:
In this case, the patient did not have naloxone ordered despite receiving a high-risk combination of Demerol, Vistaril, and Morphine. This represents a significant lapse in established safety protocols. A standing order for naloxone, combined with appropriate monitoring, could have potentially prevented the adverse outcome. The combination of these medications can severely depress the central nervous system and respiratory drive, increasing the risk of a fatal event. Unfortunately, the absence of critical safety measures in this case contributed to a preventable death.

EBP Intervention:

According to Champagne, Fecek, and Goldstein (2023), naloxone is a critical medication that can save lives by reversing the dangerous effects of opioids. It should always be included when patients are receiving opioid medications, especially with patient-controlled analgesia (PCA). A standing order for naloxone should include administering 40 mcg IV if the respiratory rate drops to eight breaths per minute, followed by an additional 80 mcg IV if it does not increase to at least ten within two minutes. If the patient exhibits decreased arousal, an arterial blood gas should be obtained. If carbon dioxide levels are elevated, a low-dose naloxone infusion and ventilatory support may be necessary. The goal is to reverse respiratory depression while maintaining adequate pain control. Patients should be closely monitored with continuous tools such as pulse oximetry, telemetry, and frequent vital sign assessments. Many places recommend including naloxone as a standing order when prescribing high-risk opioids such as morphine.

Why: Naloxone could have prevented the opioid-induced respiratory depression if administered promptly. Timely administration may have ultimately prevented the patient’s death.

Impact: The missing standing naloxone order and appropriate monitoring led to a preventable death, highlighting the urgent need for evidence-based safety protocols in opioid administration.

# data[].attributes.headline
Intervention 4: Designated Critical, Safety Zones in Preoperative Area

# data[].attributes.subject
Intervention 4: Designated Critical, Safety Zones in Preoperative Area

# data[].attributes.body
Lack of Critical, Safety Zones: The preoperative area is crucial because it ensures that the patient is ready for surgery. Proper safety protocols and physical assessments are done by various providers. While Louise Batz was in the preoperative area, both her legs were marked for surgery instead of just one. What made the situation worse was that the patient's sister caught the mistake just in time, instead of a healthcare provider. There was a lack of critical, safety zones in which there were minimal distractions and interruptions. This can lead to increased mistakes which can, unfortunately, be detrimental to the health of patients. The Joint Commission has recommendations to create safety zones before tasks of high risk (Agency for Healthcare Research and Quality, 2019). This is commonly seen in the operating room prior to conducting surgeries.

EBP Intervention: Implement critical, safety zones in the preoperative area so that there is increased quietness and minimal distractions.

Why: These zones can lead to proper verification of the patients on whether they are ready for surgery. Dedicated zones of minimal distractions create comfortable spaces for providers to gather and discuss all the safety protocols and assessment results efficiently.

Impact: Less mistakes can happen in the first place and when a mistake does in fact occur, a healthcare provider can catch it rather than the patient or family member. In Louise Batz's case, if critical, safety zones were implemented in the preoperative area, then perhaps the correct leg would have been marked for surgery. Or if the incorrect leg was marked, then the critical, safety zone would have allowed for proper verification processes to catch the mistake.

# data[].attributes.headline
Intervention 5: Family Engagement as a Patient Safety Strategy

# data[].attributes.subject
Intervention 5: Family Engagement as a Patient Safety Strategy

# data[].attributes.body
Family Engagement: A structured approach that involves educating and empowering family members to participate in monitoring, decision-making, and communication to enhance patient safety.

Patient Safety Events: Preventable incidents like unrecognized opioid overdose, adverse reactions, or clinical decline that occur due to missed warning signs or delayed action.

Jha and Madden (2024) emphasize that family members are often the first to recognize subtle changes in a patient’s condition—especially in the postoperative period. In “Unmonitored: A Post‑Surgical Narcotic Overdose in the Hospital (The Story of Louise Batz),” Louise’s family noticed early signs of oversedation and cognitive decline, yet their concerns were dismissed or minimized by staff. If a structured family engagement protocol had been in place—such as teaching them how to recognize opioid toxicity or empowering them to call a rapid response team—Louise’s deterioration may have been caught earlier, potentially preventing the tragic outcome. This highlights the life-saving potential of making families active partners in care.

EBP Intervention: Implement structured family education and escalation protocols (e.g., SBAR for families, Condition Help) to allow families to identify and act on signs of deterioration.

Why: Families can detect changes between routine checks and advocate when patients are too sedated or vulnerable to speak for themselves.

Impact: Could have allowed Louise Batz’s family to escalate their concerns earlier, leading to faster intervention and possibly avoiding irreversible harm.

# data[].attributes.body
Agency for Healthcare Research and Quality. (2019). Patient safety in the surgical environment: Distractions in the operating room. AHRQ Patient Safety Network. https://psnet.ahrq.gov/issue/distractions-operating-room

Al-Anati, A., Molloy, L., Sim, J., Halcomb, E. & Frost, S. (2024) Structured interactions between nurses and patients through intentional rounding: A scoping review. International Nursing Review, 71, 492–503. https://doi.org/10.1111/inr.12984

Champagne, K., Fecek, C., & Goldstein, S. (2023). Patient-Controlled Analgesia. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564409/.

Jha, A. K., & Madden, J. M. (2024). Family engagement and patient safety: How family members can help reduce harm. NEJM Catalyst Innovations in Care Delivery, 5(3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11836844/

Vockley, M. (2013). Silent danger: opioids, PCA pumps, and the case for continuous monitoring. Biomedical instrumentation & technology, 47(6), 454-465.