Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring

Preventing “Dead In Bed Syndrome” with Patients After Surgery

by Michael Wong

In our recently conducted survey among healthcare providers, almost all the respondents (85%) favor the development and use of safety checklists.

Because of this strong desire of healthcare professionals to have a checklist, PPAHS is putting together a working group to create a checklist targeted towards patient-controlled analgesia. This checklist would reinforce the need for continuous electronic monitoring for oxygenation and ventilation. For studies and Anesthesia Patient Safety Foundation recommendations on patient-controlled analgesia, please click here.

“We should stop the found dead in bed syndrome,” says Dr. Andrew Kofke (Co-Director at Hospital of the University of Pennsylvania Neurocritical Care Program). “The use of a well-constructed checklist that ensures proper procedures are followed in patient-controlled analgesia would enhance patient safety.”

An example of a checklist is the surgical checklist that was created and is being promoted by the World Health Organization and through the efforts of Dr. Atul Gawande (Associate Professor of Surgery at Harvard Medical School and General and Endocrine Surgeon at Brigham and Women’s Hospital).

“Avoidable failures are common and persistent, not to mention demoralizing and frustrating,” Dr. Gawande says. “And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correct, safely, or reliably.”

“A checklist would help ensure that necessary procedures are followed when a patient is provided with a PCA pump,” explains Dr. Elliot Krane (Director, Pediatric Pain Management at Lucile Packard Children’s Hospital at Stanford).

“When there is a handoff of a patient from team to team, or location to location (such as OR to PACU, OR to ICU, ICU to OR, etc.), I have been impressed that there are times in which things fall through the cracks, from relatively minor things like missed doses of antibiotics, to critical things like ventilators not being properly connected, potentially resulting in hypoxia,” says Dr. Krane.

Do you think that a succinct checklist (5 or 6 key items) targeted at patient-controlled analgesia would enhance patient safety?

If you may be interested in assisting to develop such a checklist, please email PPAHS at mike.ppahs@gmail.com

2 thoughts on “Preventing “Dead In Bed Syndrome” with Patients After Surgery

  1. This should be a requirement for all healthcare professionals. Checklists create protocol and accountability. How would you actually enforce the service providers to do the work on the checklists? On a side note this type of procedure and practices are equivalent to a safety manual employers have for their workers which can provide discounts on workers compensation insurance. I imagine that if this practice was implemented and practiced properly than there is a chance the service provider could receive discounts on their medical malpractice insurance.

  2. Healthcare professionals should have checklists in place for everything. Doctors, nurses and PAs work in stressful environments were a single thing could be forgotten. This reminds me of an episode from Grey’s Anatomy (bad example right? hear me out first) where Dr. Kepner forgot to check a patient’s throat. She was distracted by a startling case of a man with a metal bar through his chest. Her patient ended up dying because of severe smoke inhalation. A board determined it was her inaction when the patient first arrived that resulted in the patient’s death.

    I know GA as well as other medical shows add drama but it isn’t so farfetched. Checklists, which by the way Kepner created eventually for surgical cases, can help improve patient care and reduce preventable deaths.

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