title: Postoperative opioid-induced respiratory depression: a closed claims analysis.
abstract: BACKGROUND
  Postoperative opioid-induced respiratory depression (RD) is a significant cause of death and brain damage in the perioperative period. The authors examined anesthesia closed malpractice claims associated with RD to determine whether patterns of injuries could guide preventative strategies.
  
  
  METHODS
  From the Anesthesia Closed Claims Project database of 9,799 claims, three authors reviewed 357 acute pain claims that occurred between 1990 and 2009 for the likelihood of RD using literature-based criteria. Previously cited patient risk factors for RD, clinical management, nursing assessments, and timing of events were abstracted from claim narratives to identify recurrent patterns.
  
  
  RESULTS
  RD was judged as possible, probable, or definite in 92 claims (κ = 0.690) of which 77% resulted in severe brain damage or death. The vast majority of RD events (88%) occurred within 24 h of surgery, and 97% were judged as preventable with better monitoring and response. Contributing and potentially actionable factors included multiple prescribers (33%), concurrent administration of nonopioid sedating medications (34%), and inadequate nursing assessments or response (31%). The time between the last nursing check and the discovery of a patient with RD was within 2 h in 42% and within 15 min in 16% of claims. Somnolence was noted in 62% of patients before the event.
  
  
  CONCLUSIONS
  This claims review supports a growing consensus that opioid-related adverse events are multifactorial and potentially preventable with improvements in assessment of sedation level, monitoring of oxygenation and ventilation, and early response and intervention, particularly within the first 24 h postoperatively.
authors.affiliation: From the Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee (L.A.L.); Department of Anesthesiology, Virginia Mason Hospital and Seattle Medical Center, Seattle, Washington (R.A.C.); Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington (L.S.S., K.L.P., G.W.T., K.B.D.); and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (T.V.-L.).
authors.forename: Lorri A
authors.initials: LA
authors.lastname: Lee
authors.forename: Robert A
authors.initials: RA
authors.lastname: Caplan
authors.forename: Linda S
authors.initials: LS
authors.lastname: Stephens
authors.forename: Karen L
authors.initials: KL
authors.lastname: Posner
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Terman
authors.forename: Terri
authors.initials: T
authors.lastname: Voepel-Lewis
authors.forename: Karen B
authors.initials: KB
authors.lastname: Domino
mesh_terms: D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000009:adverse effects*; D000758:Anesthesia / Q000009:adverse effects; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007345:Insurance Claim Review; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000139:chemically induced* / Q000175:diagnosis / Q000453:epidemiology*; D012131:Respiratory Insufficiency / Q000139:chemically induced* / Q000175:diagnosis / Q000453:epidemiology*
chemical_list: D000701:Analgesics, Opioid