Capnography, Patient Stories, PCA, Post-Operative Monitoring

Woman’s Death After Knee Surgery Calls Attention to Need for Better Monitoring

by Sean Power

The recent death of Helen Bousquet after what is being described by her son, Brian Evans, as “a basic routine procedure” at a hospital 40 minutes north of Boston highlights the need for better monitoring of patients after surgery. Mr. Evans is accusing the hospital of criminal negligence, according to an exclusive interview with Valley Patriot, as a result of how his mother’s visit to the hospital was handled by staff.

I spoke with Michael Wong, Executive Director here at the Physician-Patient Alliance for Health & Safety. He offered comments on the interview.

“Although the hospital never did an autopsy, Helen Bousquet’s sleep apnea has been listed as one of the causes of death on her death certificate,” says Mr. Wong. “Brian Evans’ interview with Valley Patriot makes it clear that his mother was on morphine and that her breathing was not continuously monitored. This combination is disastrous.”

Warned By Hospital Accreditation Body The Joint Commission

In August 2012, The Joint Commission, the regulatory body that oversees hospital accreditation, issued a Sentinel Event Alert regarding the safe use of opioids like morphine in hospitals.

“Sleep apnea is the very first characteristic of patients who are at higher risk for oversedation and respiratory depression listed in The Joint Commission’s Sentinel Event Alert,” says Mr. Wong. “The Alert’s list also includes patients who are post-surgery and patients with preexisting pulmonary or cardiac disease. Mr. Evans has stated his mother had a heart condition and just had knee surgery. There is no way Ms. Bousquet should have received morphine pain management without adequate monitoring.”

The PPAHS has had patient safety experts comment on PCA safety in the past. While we haven’t reached out for comment on this specific case, I found some pieces of insight that might be applicable.

Frank Overdyk, MD, Professor of Anesthesiology at Hofstra North Shore-LIJ School of Medicine, in an earlier discussion about The Joint Commission’s list of high-risk characteristics:

“To be honest, I look at this list, I can’t remember a patient in recent history who did not have one or more of these conditions.”

Robert Stoelting, MD, president of the Anesthesia Patient Safety Foundation (APSF), in earlier comments on preventing opioid-induced respiratory depression:

“APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients.”

Dr. Peter Pronovost, PhD, FCCM (Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality) , has previously explained:

“We have a healthcare system that relies on the heroism of our clinicians rather than designing safe systems. There is technology right now that can monitor someone.”

Peter Corsale, a lawyer with Gallop, Johnson, & Neuman, L.C., in St. Louis, Missouri, on the liability implications of the availability of technology that monitors breathing:

“Simply put, capnography is now becoming standard practice outside of the tertiary care setting.”

As I mentioned, I haven’t asked any of these experts to comment on this specific case. But it is easy to see how following these recommendations might have prevented respiratory arrest in Ms. Bousquet’s death.

Mr. Wong concludes:

“Ms. Bousquet’s death from inadequate monitoring after a routine procedure is not the first. 18 year-old Amanda Abbiehl died after being admitted to a hospital for strep throat. 11 year-old Leah Coufal died after elective surgery. 11 Year-old Justin Micalizzi died after seeing doctors about a swollen ankle. Louis Batz, a mother and grandmother herself, died from a lack of monitoring after her own knee surgery. Helen Bousquet tragically joins these other victims of inadequate monitoring.”

The Physician-Patient Alliance for Health & Safety recently released a concise checklist that reminds caregivers of the essential steps needed to be taken to initiate Patient-Controlled Analgesia (PCA) with a patient and to continue to assess that patient’s use of PCA. It is available in Microsoft Word check-able format here and can be downloaded as a PDF here.

6 thoughts on “Woman’s Death After Knee Surgery Calls Attention to Need for Better Monitoring

  1. David Henaghan

    I cannot believe this happened to this woman. It’s disgusting, and there’s no doubt the hospital will do what they all do: lie.

  2. Pingback: Crooner Brian Evans Sues Red Sox and … EVERYBODY! | The Valley Patriot

  3. Thanks for sharing your thoughts, Mike.

    Fortunately there exists a growing body of research on the use of capnography in nonintubated patients. In addition to the research cited on respiratorymotion.com, you might find these papers worth reading:

    Accuracy of capnography in nonintubated surgical patients.
    Liu SY, Lee TS, Bongard F.
    Department of Surgery, Harbor-UCLA Medical Center, UCLA School of Medicine, Torrance.
    http://www.ncbi.nlm.nih.gov/pubmed/1424873

    Advances in the Use of Capnography for Nonintubated Patients
    Krauss, Baruch, MD, EdM
    Department of Emergency Medicine, Children’s Hospital, Longwood and Department of Pediatrics Harvard Medical School, Boston MA, USA
    http://isrjem.org/isrjem_nov08%20kraus_capnography_postprod.pdf

    Me, I’m hoping healthcare technologists continue to develop monitoring equipment that provides earlier and earlier detection of respiratory depression for all patients, both intubated and nonintubated.

    Thanks again for sharing that information on monitoring nonintubated patients.

    Best,

    Sean Power
    Community Manager
    Physician-Patient Alliance for Health & Safety

    • You hit the nail on the head Sean. Technology that provides early detection of respiratory challenges is the future. I guess it wouldn’t be called monitoring anymore, it would be an early warning technology like the Respiratory Motion system.

  4. Pingback: Governors Nationwide Issuing Sleep Apnea Awareness Proclamations | NEWS.GNOM.ES

  5. Pingback: Governors Nationwide Issuing Sleep Apnea Awareness Proclamations | Just No Snoring PST

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s