Spotlight on Michael A.E. Ramsay, MD, FRCA, Baylor University Medical Center


With the opioid epidemic making headlines across the world, a silent crisis is emerging in hospitals where opioids are legally administered. The crisis is the number of preventable patient deaths due to “failure to rescue,” (FTR) patients who have exhibited opioid-induced respiratory depression and it’s one of the leading causes of preventable patient deaths in hospitals today. The concept of failure to rescue captures the idea that, although not every complication of medical care is preventable, health care systems should be able to rapidly identify and treat complications when they occur.1

But failing to identify and treat opioid-induced respiratory depression is unfortunately common with stories of patients found “dead in bed” in the hospital. That was the case for 12-yearold Leah Coufal. After undergoing successful elective surgery at a prestigious Southern California hospital, Leah was found dead in bed by her mother who was at her side but drifted to sleep, awaking only to find that her daughter had passed. Leah was a victim of undetected respiratory arrest, caused by the narcotics that were intended to ease her pain.2

Sadly, Leah isn’t alone.

In June 2009, Baylor University Medical Center recognized that they had also had a growing problem and were routinely seeing more than 40 Rapid Response Team (RRT) calls on one floor each month due to opioid-induced respiratory depression. The process Baylor University Medical Center developed forms the basis for the Patient Safety Movement Foundation’s Actionable Patient Safety Solutions (APSS) on Failure to Rescue: OpioidInduced Respiratory Depression.

“We had some really bad situations regarding “near misses” and that was unacceptable. So we created the Breathe Team and brought together everyone involved in the care of the patient. This included doctors, nurses, physicians and patient advocates. It was a just like what the Patient Safety Movement does with the Actionable Patient Safety Solutions,” recalls Dr. Michael A.E. Ramsay MD, FRCA Chairman, Department of Anesthesiology and Pain Management at Baylor University Medical Center.

The Breathe Team met weekly and looked at the causation for each failure to rescue event including what happened, what could be done to prevent these events. They examined each case from opioid-induced respiratory depression with the same scrutiny and methodology of a plane crash.

“It’s time-consuming, but you have to do it. At first, we examined whether we could identify predictors of who would be sensitive to opioids. For example, were overweight people more sensitive? But what we found was that you couldn’t predict opioid sensitivity. Anyone could be sensitive to opioid arrest,” explained Dr. Ramsay.

As a result, the Breathe Team was able to identify specific process improvements for the hospital and educate staff. The Baylor Breathe Improvements included:

• Standardized post-operative opioid (PCA) order sets. Over 50 different sets existed previously.

• Stopped continuous PCA in opioid naïve patients

• Instituted the “Oxygen Withdrawal Trial” in PACU – a test for respiratory depression.

• Screened pre-operatively for patients at increased risk for respiratory depression and applied a blueberry wristband

Among the new standardized protocols included continuously monitoring all patients.

“It’s not standard practice in hospitals to put people on monitors, but people are now beginning to understand how dangerous these drugs are, and non-invasive monitoring technology is now becoming commonplace. It reaching the stage where we can monitor continuously and unobtrusely, all patients and be alerted when they are getting into trouble ” explains Dr. Ramsay. “It is using similar technology that more and more people are using everyday to monitor heart rate, steps walked, calories burned.”

As a result of the changes, Baylor University Medical Center went from 40 monthly rapid response team activations a month to three, and these are early calls. Due to the continuous monitoring of patients, staff are warned early enough to identify and treat patients, preventing costly return to ICU stays. It has saved the hospital money and more importantly kept patients’ safe.

Baylor University Medical Center’s success in addressing Failure to Rescue formed the basis for the Patient Safety Movement’s APSS. And given the diligence the hospital used to address Failure to Rescue, it is no surprise that they have used resources, including the APSS, to address other areas to improve patient safety.

“The APSS are written as a recipe. You can get all the other hospital staff involved; you can adjust the APSS and make them work for the individual challenges a hospital is facing, Patient safety is a team effort.”

Dr. Ramsay, MD, FRCA Chairman, Department of Anesthesiology and Pain Management, Baylor University Medical Center, and President of Baylor Scott & White Research Institute


1 Agency for Healthcare Research and Quality (2017, November) Patient Safety Primer. Retrieved from website:

2 Patient Safety Movement Foundation (2014) Leah Coufal’s Story. Retrieved from website: