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.

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.

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.

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.

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.

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.