Capnography, Patient Stories, Patient-Controlled Analgesics, PCA

Notre Dame class project: improving patient safety through monitoring

by Michael Wong

18-year old Amanda Abbiehl tragically died in 2010 at Saint Joseph Regional Medical Center (SJRMC).

The cause — a PCA (patient-controlled analgesia) pump error. As the petition filed with Indiana’s Patient Compensation Fund states:

“Against her treating physician’s orders, Amanda was given a constant dose of Hydromorphone once she was connected to the PCA pump … Amanda’s family, as well as SJRMC staff, have indicated it took several staff members a long time to program the pump.”

As Amanda’s father says:

“My wife and I believe in our hearts and minds that had there been a protocol in place requiring the use of a monitor … she would still be with us today.”

So, what does a class at University of Notre Dame do in the face of this tragedy?

The class is helping “design materials to convey their message to medical professionals as well as the general public”. According to their professor, Robert Sedlack, this project was inspired when the students heard about the death of Amanda.

To assist with this project, at the request of Amanda’s parents and Notre Dame’s class, the Physician-Patient Alliance for Health and Safety (PPAHS) and three other healthcare experts were invited to discuss PCA errors, the role of technology in improving patient safety (such as “smart” PCA pumps with integrated capnography being used at Veteran Health Administration and St. Joseph’s/Candler hospitals). (For a pdf of the PPAHS presentation, please here.)

So, here are two key questions that the class has:

  • Who are the patient safety champions who would lead the charge in implementing smart PCA pumps at hospitals (e.g., anesthesiologists, nurses, respiratory therapists)?
  • What information would these champions need to have to affect change in their organizations?

What do you think?

8 thoughts on “Notre Dame class project: improving patient safety through monitoring

    • Great question. I would encourage a lawyer or legal nurse to provide their thoughts.
      Sadly, Justin, Louise, Leah, and Amanda are “just the tip of the iceberg” (to paraphrase Dr Richard Dutton, executive director, Anesthesia Quality Institute, on PCA errors).

  1. The Beasley Firm, who are Philadelphia personal injury trial lawyers, just posted their thoughts on PCA errors. The title of their article probably says it all, “Patient’s On Patient Controlled Anesthesia (PCA) Pain Pumps Should Not Die Due To Respiratory Failure or Breathing Problems” – bit.ly/wczlIt

  2. Carey

    Anesthesiologists understand the effects of intravenous narcotics best and are safety advocates. Hospital policy needs to facility patient safety. Nurses are the voice of the patient during the hospitalization and are the monitor of patient comfort and over sedation.
    PCA pumps that have an end tidal monitor of CO2 should be incorporated into each PCA device. It is also my belief that a continuous infusion of narcotics should be only added after determining the demand doses of narcotics after the patient is made comfortable and over an eight hour shift.

  3. Brother

    It’s so sad that these beautiful people could still be alive if they were only monitored with CO2 monitor. What a waste, shame on the hospitals for not putting patient safety first.

  4. lenoreac

    we each have the ability to insist a doctor writes the order for continuous monitoring. Until that is the standard, I would not leave anyone in the hospital without a monitor.

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