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

Third Leading Cause of Death is Preventable

Dr. Peter Pronovost (PhD, FCCM, Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient) recently appeared on the Katie Couric Show on “Shocking Medical Mistakes”.

On the Show, Dr. Pronovost discussed the number of preventable deaths that occur each year in the United States:

Frame the size of your problem. I suspect that all of your viewers either have been touched by or a family member has been harmed by mistakes. It is the third leading cause of death in this country. More people die from medical mistakes each year than died per year in the civil war.

Additionally, following the discussion of Leah, the 11-year old girl who tragically died after receiving fentanyl from a patient-controlled analgesia (PCA) pump and was not monitored, Dr. Pronovost said there is monitoring technology that exists today,

There is technology right now that can monitor someone, if their breathing is going slow. We are not there yet but we should be able to automatically shut off the pain medicine like any other industry would do. Say your breathing has gone too slow, it’s unsafe. Let’s have a safeguard and we don’t have that yet.”

The “automatic shut off” that Dr. Pronovost mentions is what engineers call a “forcing function”.

Bryanne Patail, biomedical engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety explains the importance of a “forcing function” and how PCA pumps with a ”forcing function” are currently being used at Veteran Affairs:

Use of PCA pumps is a process, and improving that process is an area that involves many stakeholders. In looking at fixes, they can be categorized as strong, intermediate or weak fixes. The strongest fix for PCA pumps is a forcing function, such as an integrated end tidal CO2 monitor that will pause the pump if a possible over infusion occurred. So, healthcare providers should first look at these strong fixes. There they will see the most impact on reducing errors and improving patient safety.

Mr. Patail says that use of PCA pumps with a forcing function can prevent more than 60 percent of related adverse events:

One action that VHA has taken to address this high error incident rate is to use a PCA pump that has an integrated end tidal CO2 monitor or capnograph. A capnograph measures in real-time the adequacy of ventilation. Using this technology could prevent more than 60 percent of adverse events related to PCA pumps.

In addition, we developed a standard protocol that looks at the other key issues that need to be addressed for safe use of PCA pumps: human factors (communication, training, fatigue and scheduling); the environment and equipment, rules, policies and procedures, and barriers and controls.

We look forward to hearing from Veteran Affairs how much better than 60 percent their use of PCA’s with this forcing function has achieved.

Stopping all preventable deaths is the goal. As Dr. Pronovost emphasized:

We need to set a goal to eliminate these preventable deaths and work collaboratively to make sure it never happens

 To watch the Katie Couric show on Shocking Medical Mistakes, please click here

One thought on “Third Leading Cause of Death is Preventable

  1. Pingback: The Doctor Weighs InThe Need for Standards in Healthcare: For Improved Patient Safety and Quality of Care

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