20/20 Hindsight:
If we only knew we could have saved lives

by Mary Jahrsdoerfer,

Excerpt of note from 17-year-old family member, to hospital CNO

“My Aunt Maude, she died last night. She was young and healthy…I just don’t understand what could have possibly happened to cause her rapid deterioration. She was only 38 years old, an avid runner, teacher, and mom. My Aunt only went in for knee surgery. Please help me to understand what went wrong. Please, my family needs to know.”

As a clinician…

Have you ever looked back and asked yourself, why didn’t I notice that before? Or, how did I miss that? Whatever ‘that’ may be – When you place these same principled questions into your own clinical experience with an adverse patient event, it often raises more frustrating questions, than answers. Until now.

Objective Opinion

In a recent independent report by the Spyglass Consulting Group1, they set out to assess the overall knowledge and challenges of 30 clinical informatics luminaries at leading hospitals and health systems within the United States who are developing their own strategy for real-time clinical surveillance and analytics. All voiced their deliberate need to proactively identify patients who may experience deteriorating or life-threatening conditions. You see, the problem stated above, by the 17-year-old, whose healthy Aunt that went into the hospital for routine surgery and passed away, is not an isolated incident, but rather one that is quite ubiquitous in acute-care delivery today. It is instances like this, that drive healthcare leaders to search for early warning signs and trigger trends that would prevent escalations in patient care because of adverse conditions that arise in the hospital.

Aunt Maude’s Case

A 38-year-old, active female presents to the hospital for a planned overnight stay after surgical repair of a grade III anterior cruciate ligament (ACL) tear. This type of advanced knee injury is extremely painful. Admitted to an orthopedic-surgical unit post-operatively, patient vital signs are measured once every four hours, or as I call it…the “Kodak-moment” …since it is simply a snap-shot in time, rather than continuous recording. The physician ordered hydromorphone administered through a PCA pump. The night nurse is scheduled to round at 12-midnight and then again at 4:00 am. That same nurse however, got side-tracked with an emergency in a different room at the 4 o’clock hour, finally making it to Aunt Maude’s room just before 5:00 am. Horrified, the nurse found her patient completely unresponsive. Aunt Maude was dead-in-bed due to complications from opioid-induced-respiratory-depression (OIRD). Without continuous clinical surveillance, there were no warnings (especially with the room-lights out and the patient asleep), which would have signaled to the nurse that the patient was in respiratory distress.

Regulatory Changes

Over the last several years, regulatory agencies have challenged healthcare leaders to examine the concept of broader utilization of continuous clinical surveillance. The intent is to recognize developing vital trends that may endanger a patient’s physiologic homeostasis, particularly as it related to the administration of opioids. Administrative and clinical leaders should be able to ‘check-off’ the following directives and recommendations when creating policies and procedures for their institution:

  • “Create and implement policies and procedures for the ongoing clinical monitoring of patients receiving opioid therapy.”2 TJC, Sentinel Event Alert, 2012
  • “Monitor the use of opioids to determine if they are being used safely,” to include the tracking of adverse events (such as opioid-induced respiratory depression, OIRD).3 TJC, Sentinel Event Alert Update, 2017
  • Patient “monitoring needs to be ‘documented’ and the time between documentation must ‘not exceed 2.5 hours’4. CMS quality measure #3040. CMS, 2013
  • “Minimum adequate provisions must be made for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.”5 CMS, 2014

Industry Recommendation

In fact, many clinical associations and patient safety organizations including the Anesthesia Patient Safety Foundation (APSF), American Association for Respiratory Care, American College of Clinical Engineering, Hospital Quality Institute and others have come forward to advocate for continuous monitoring of all patients receiving opioids. The ASPF issued its own specific guidance – “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.”6. APSF in Becker’s Review, 2014

Is clinical surveillance an investment priority?
What’s in it for us? Aka…ROI


  • Patient Safety – Risk Strategy focus for Nursing, Nurse Leaders, Physicians, Quality, Risk Management

Value Assumptions:

  1. Improve care quality and outcomes. Avoid care escalations
  2. Reduce clinical variation. Reduce clinical subjective judgement regarding decisions
  3. Reduce health care costs. Avoid penalties by keeping hospital readmission rate down
  • Regulatory Compliance and Cost Reduction focus for Executive Leadership, CFO, Legal, Hospital Marketing

Value Assumptions:

  1. Adherence to CMS Regulations. Finding avenue to help close the gap on extended patient. stays
  2. Innovative Real-time Technology.  Long term investment in cost reduction patient technology= ROI
  3. State-of-Art Care. High quality care facility attracts top physicians. Cyclical phenomenon.

Let’s sum it all up

How would you respond to the 17-year-old-girl if you were the one who received her letter? A tragic event occurred in her family that could have easily been avoided. We are in an advanced technological era…yes, even in healthcare…especially in healthcare. Let’s utilize the smart tools in our toolbox for the work that needs fixing. In scrutinizing this particular patient case, continuous clinical surveillance was not only warranted, the hospital was potentially liable, fundamentally accountable, and ethically responsible.

Let’s be the change-agents that lead the initiative to prevent an adverse clinical event from occurring again.

Figure 1, below, illustrates the negative attributes in our technologically-driven, acute-care hospital environment, that may lead to a gap or breach in patient care. The luminaries interviewed, agree that if we can address these gaps in practice, we can help to eliminate adverse patient events.

clinical surveillance breach diagram


  1. Malkary G. 2018 Healthcare Without Bounds Trends in Clinical Surveillance and Analytics. Spyglass Consulting Group, Menlo Park, CA.
  2. The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. Issue 49; August 8, 2012. Available at: www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf.
  3. The Joint Commission. Joint Commission enhances pain assessment and management requirements for accredited hospitals. Perspectives. 37(7); July 2017. Available at: www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_
  4. S. Department of Health & Human Services. Requirements for hospital medication administration, particularly intravenous (IV) medications and post-operative care of patients receiving IV opioids. Centers for Medicare and Medicaid Services. March 14, 2014. Available at: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-15.pdf.
  5. Wong M. What does new CMS guidance on monitoring post-operative patients receiving opioids mean for hospital practice? PSQH. July 15, 2014. Available at: www.psqh.com/news/what-does-new-cms-guidance-on-monitoring-post-operative-patients-receiving-opioids-mean-for-hospital-practice.
  6. Becker’s Hospital Review. New CMS guidance recommends monitoring of all patients receiving opioids: what it means for healthcare providers. June 2, 2014. Available at: beckershospitalreview.com/quality/new-cms-guidance-recommends-monitoring-of-all-patients-receiving-opioids-what-it-means-for-healthcare-providers.html

About the Author:

Mary Jahrsdoerfer,

Dr. Mary Jahrsdoerfer is a clinical authority in emerging healthcare technology, bridging the gap to safe clinical practice and patient safety in the acute care setting. Mary currently serves as Senior Advisor in Clinical Informatics at Bernoulli Healthcare, with a focus of improving patient safety in real-time through clinical analytics. Dr. Jahrsdoerfer is also currently an Assistant Professor of Graduate Studies in Healthcare Informatics at Adelphi University in New York. Prior, she held leadership roles including the Chief Nursing Officer for Extension Healthcare (now Vocera Communications), and Clinical Research Scientist and Clinical Consultant at Philips Healthcare Mary has her clinical foundation as a critical care nurse, with a focus in cardiology. Mary has many years of experience on the front lines of nursing, hospital leadership, and complex program development, at various healthcare systems in the northeastern United States. Her career interests grew to emerging healthcare technologies specific to patient safety.

Dr. Jahrsdoerfer’s educational accomplishments include:

  • BSN, Stony Brook University
  • MHA, Long Island University
  • PhD, UMass Amherst
  • Member, Sigma Theta Tau International Honor Society
  • Fellow, NY Academy of Medicine