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

8 Key Points to Improving Patient Safety: Physician-Patient Alliance for Health & Safety Presents at AORN Annual Conference 2014

At the annual conference of Association of periOperative Registered Nurses (AORN), which took place March 30 – April 2, 2014, the Physician-Patient Alliance for Health & Safety (PPAHS) presented eight key points to improve patient safety and health outcomes.

Three of the most commonly overlooked clinical points are:

  • Verify hand–off or transition of care from nurse-to–nurse that continuous electronic monitoring is in place, has been maintained and double-checked.
  • Double check PCA dosing, pump parameters, and continuous monitor settings.
  • Include in the post-operative orders daily lead changes and hands off communication on lead changes to decrease nuisance alarms.

Lynn Razzano RN, MSN, ONCC (Clinical Nurse Consultant for PPAHS), who represented PPAHS at the AORN conference, says that the tremendous interest shown by AORN nurses in the PPAHS presentation shows how important is the proper management and monitoring of patients receiving opioids. Ms. Razzano recounts what conference attendees told her about the vital need to order continuous electronic monitoring:

“Perioperative nurses emphasized to me that they should be the identified patient advocate for safety and ensure all patients receiving opioids are ordered continuous electronic monitoring. Although perioperative pace is hectic and there is tremendous pressure to conduct quick operating room turnover, perioperative nurses can never forget that their commit to the patient does not end following surgery. Following surgery, the post-operative order for continuous electronic monitoring should be made for all patients receiving opioids.”

The eight key clinical relevant points were contained in poster presentation #29 entitled, “First National Survey of Patient –Controlled Analgesia Practices: Results and Implications for Standards, Nursing Assessment and Patient Safety”. Please click here to view a PDF of the handout of the PPAHS poster.

About Physician-Patient Alliance for Health & Safety

Physician-Patient Alliance for Health & Safety is an advocacy group whose mission is to promote safer clinical practices and standards for patients through collaboration among healthcare experts, professionals, scientific researchers, and others, in order to improve health care delivery. For more information, please go to

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

Why You Should Let Patients Participate in PCA Safety Checklists, Too

by Sean Power

(This article first appeared in Healthcare News.)

Last month, in an Outpatient Surgery e-weekly newsletter, Jim Burger shared research by Tulane University Hospital and Clinic in New Orleans, suggesting that surgical teams are more likely to use the World Health Organization’s (WHO) Surgical Safety Checklist when patients know about the existence of such checklists. All of the informed patients said that knowing about the checklist made them feel more comfortable going into surgery.

In the study, which was presented at the American Society of Anesthesiologists’ conference, students secretly monitored 104 procedures. In 43 cases, patients were told about the checklist; in the other 61 procedures, patients were left in the dark.

According to the article, compliance on all of the items on the checklist was higher when patients were aware of its existence.

Below, I outline three reasons why, like the WHO Surgical Safety Checklist, you should share the Patient-Controlled Analgesia PCA Safety Checklist with your patients.

1. Evidence-based checklists improve patient safety. Sharing checklists with patients will increase patient confidence, comfort, and satisfaction.

Peter Pronovost, MD, 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 Care), describes the process of translating evidence into practice:

  • Summarize the evidence in a checklist.
  • Identify local barriers to implementation.
  • Measure performance.
  • Ensure all patients get the evidence.

Evidence should guide decisions. Since checklists summarize evidence it is crucial that physicians comply with the steps outlined by checklists.

Based on the Tulane research, patients will feel more confident, more comfortable, and more satisfied when they see the PCA Safety Checklist before they receive anesthesia.

2. Checklists help communicate with patients and families and clarify the patient’s role in safe care.

Since checklists are evidence-based, when you share them with patients you effectively give them a crash course on all of the evidence behind the care that they are about to receive.

Physician compliance to checklists, demonstrated by the Tulane study, is important to safe care. Patient compliance is equally important. When patients understand what is expected of them in light of the evidence at hand, they are more likely to comply.

For example, some patients receiving PCA complain of discomfort from the capnograph’s nasal cannula that measures carbon dioxide in exhalations. When nurses explain the importance of capnography, and that measuring end tidal CO2 can alert medical staff if the patient has stopped breathing, patients become more willing to comply.

Tammy Haslar, Oncology Clinical Nurse Specialist at the Franciscan Alliance at St. Francis Health, suggests nurses discuss the monitoring program “during pre-op appointments” and “while going over surgery instructions.” Doing so sets expectations for the patient and offers reasons for complying with safety measures.

Sharing the PCA Safety Checklist with patients before their operation helps to make sure that nothing is overlooked and that expectations are communicated clearly. This communication will increase the likelihood that patients fulfill their own expectations.

3. Sharing checklists with patients fosters a culture of transparency.

Dr. Pronovost explains that transparency prevents harm:

“To be accountable for patient harms, health care needs valid and transparent measures, knowledge of how often harms are preventable, and interventions and incentives to improve performance.”

Transparency with patients promotes accountability, which leads to safe care. Accountability both rewards good behavior and deters poor performance. Sharing checklists with patients enables them to participate in the accountability discussion.

The PCA Safety Checklist is a free resource offered by the Physician-Patient Alliance for Health & Safety that was developed by a multidisciplinary team of experts. It is designed to minimize adverse events associated with PCA. You can download Word version here or a “checkable” PDF here.

Have you shared the PCA Safety Checklist with your patients? What kind of reaction did you receive?

Alarm Fatigue, Capnography, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

Perspectives on Opioid Safety and Continuous Electronic Monitoring

by Sean Power
March 11, 2014

In honor of Patient Safety Awareness Week last week, the Premier Safety Institute gathered experts on opioid safety to participate in a webinar discussion. The panel, moderated by Gina Pugliese, RN, MS, vice president, Premier Safety Institute, Premier Inc., featured several authorities on opioid safety, including:

  • Michael Wong, JD, executive director, Physician-Patient Alliance for Health and Safety
  • Harold Oglesby, RRT, manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System
  • Joan Speigel, MD, assistant professor, anesthesiology, Harvard Medical School and Beth Israel Deaconess Medical Center
  • Bhavani S. Kodali, MD, associate professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School.

You can listen to the full recording here, download the slides here, and learn more about opioid safety here.

This article is the first of a two-part series. It summarizes the presentations on opioid safety. The second part will recap the question and answer period with the entire panel.

Will continuous monitoring become a standard of care for patients receiving patient controlled analgesia (PCA)?

The Physician-Patient Alliance for Health and Safety teamed up with A Promise to Amanda Foundation to conduct the first-ever national survey on PCA practice.

“Part of the impetus for the survey was the sheer number of respiratory events that occur each year,” says Mr. Wong.


Between 20,000 and 676,000 PCA patients will experience opioid-induced respiratory depression every year.

“However for our purposes, and for A Promise to Amanda, the main impetus is the patients,” Mr. Wong continues.


The survey was developed with input from a number of patient safety experts including Richard Dutton, MD, MBA, Executive Director of Anesthesia Quality Institute, and Frank Federico, RPh, Executive Director of the Institute for Healthcare Improvement, Patient Safety Advisory Group, The Joint Commission, among others.

Six patient risk factors have been identified by major health care organizations like The Joint Commission and Institute for Safe Medication Practices (ISMP). These risk factors include:

  • Obesity
  • Low body weight
  • Concomitant medications that potentiate sedative effects of opiate PCA
  • Pre-existing conditions (such as asthma, chronic obstructive pulmonary disease, and sleep apnea)
  • Advanced age
  • Opioid naive

“The survey results show great variability in the risk factors being considered by hospitals across the country,” adds Mr. Wong.

According to the survey results, less than 40 percent of hospitals are considering all six patient risk factors.

Almost one out of five hospitals are not assessing patients for being opioid naïve. Three out of ten hospitals do not consider obesity as a patient risk factor. Three out of 20 hospitals do not consider advanced age.

Approximately 70 percent of PCA adverse events are due to errors associated with pump use, according to the Pennsylvania Patient Safety Authority. Double-checks advocated by ISMP and others can prevent errors from happening.

Patient identification, allergies, drug selection and concentration, dose adjustments, PCA pump settings, and line attachments all need to be double-checked.

“There is a great variation between hospitals performing these very simple six double checks. Sadly, only slightly more than half of all hospitals are performing all six double checks,” says Mr. Wong.

The PCA survey, conducted prior to The Joint Commission’s National Patient Safety Goal on alarm safety, found that 95 percent of hospitals are concerned about alarm fatigue. Almost nine in ten hospitals (87.8 percent) believe that a reduction of false alarms would increase the use of patient monitoring devices like an oximeter or capnograph.

“Hospitals also indicated the value of continuously electronically monitoring their patients receiving opioids,” says Mr. Wong. “All those who reported monitoring said that monitoring reduced adverse events and hospital expenditures, or that it was too early to determine the effect of monitoring.”

Moreover, hospitals using smart pumps with integrated end tidal CO2 (EtCO2) monitoring were almost three times more likely to have had a reduction in adverse events or a return on investment in terms of a reduction in costs and expenses.

The challenge of balancing effective analgesia with safety

Mr. Oglesby was involved in implementing continuous electronic monitoring at St. Joseph’s/Candler Hospitals in Savannah, Georgia, and has spoken about being opioid-related event free for eight years, as well as the return on investment that came with the program.

SJ/C is the largest health care system in southeast Georgia with 675 beds and approximately 25,000 annual discharges. In the two years preceding the implementation of continuous electronic monitoring, SJ/C experienced three opioid-related events with serious outcomes.

“We made sure that we used smart pumps to address the appropriate programming of our pumps. We also wanted to assess what would be the best way of monitoring our patients,” says Mr. Oglesby.

The team that drove the continuous monitoring program was initially comprised of pharmacy and nursing staff. Respiratory therapy was called in to address monitoring options early on in the decision making process.

According to Mr. Oglesby:

“We were specifically asked that question: as respiratory therapists, what did we think would be the earliest indicator of problems with ventilation versus saturation? We quickly said that capnography would be the earliest indicator of ventilatory problems.”

Since the nursing team was new to capnography, and since respiratory therapists were new to pain scales, education was central to the success at SJ/C.

Patient education was equally central.

“We put respiratory therapy in the role of being bedside educators,” says Mr. Oglesby, since respiratory therapists have a good foundational understanding of EtCO2 and its limitations.

“There were times when we would get calls to the bedside from the nursing staff who would say that this patient’s alarm was going off, and going off for no reason,” says Mr. Oglesby. “When you get to the bedside you would go back and review the patient’s trends and look at the waveforms. You would actually see that the patient had good reason for the alarms going off.”

The respiratory therapists found that patients often experienced undiagnosed sleep apnea and that the patients were having moments of apnea.

According to Mr. Oglesby:

“The education at the bedside resulted in the nursing staff becoming really good at using end tidal CO2 to the point that they would take monitors and put them on other patients that weren’t receiving PCA just to do an assessment of those patients.”

Capnography also provided the earliest indication of respiratory depression for patients receiving PCA treatment.


These screens from an actual patient highlight a few key points about the effectiveness of capnography at providing the earliest indication of respiratory compromise.

“You can see on that monitor that it gives you the time,” explains Mr. Oglesby. “Highlighted on both is 10:00 AM. At 10:00 AM you see the patient’s morphine dose was 2.5 milligrams. The patient’s [oxygen] saturation was 97 percent. Pulse ox was 88. The end tidal CO2 was 43 and the respiratory rate was 20.”

Mr. Oglesby explains that at 10:30 AM, the screens show, EtCO2 rose to 50, which was outside of the established range, and an alarm sounded. The pulse oximeter alarm did not sound until 11:30.

“This was typical,” says Mr. Oglesby. “We were finding that the end tidal CO2 gave us at least that hour window—gave us an hour earlier indication that something was changing with the patient’s status. So if we just had pulse oximetry, we wouldn’t have known until an hour later that something was really going on with that patient.”

According to Mr. Oglesby:

“We truly believe that end tidal CO2 provides us with the earliest indicator of a decline in our patient’s respiratory function.”.

Monitoring patients receiving PCA with capnography at SJ/C resulted in an increased likelihood of better-sustained pain control, faster recovery and discharge, a better patient experience, and eight years of event free usage of PCA therapy.

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

Identifying Risk of Respiratory Compromise for Patients Using Patient-Controlled Analgesia: Lessons Learned from a National Hospital Survey

In an article recently published in the Society of Anesthesia & Sleep Medicine newsletter (page 4), Michael Wong, JD and Lynn Razzano, RN, MSN, ONCC discuss identifying risk of respiratory compromise for patients receiving patient-controlled analgesia (PCA).

As noted by SASM’s editor (page 2), Satya Krishna Ramachandran, MD, FRCA (Assistant Professor in Anesthesiology and Director of Perioperative Quality Improvement, University of Michigan):

This newsletter contains articles that span preoperative screening, implementation of a screening tool in the electronic health record and the development of a PCA safety checklist. Michael Wong and Lynn Razzano present the findings of their 2013 survey of 40 hospitals regarding PCA safety and propose the development of a PCA safety checklist. They identify significant safety gaps in knowledge, screening, ongoing assessment and monitoring of patients on PCA. Such work is crucial to our refinement of monitoring standards and lays the platform for future observational research. 

To read a full copy of the article, please click on this link:

Capnography, Monitoring Liability and Costs, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

PPAHS Joins Anesthesia Patient Safety Foundation in Call for a “Paradigm Shift” in Opioid Safety

by Sean Power
February 19, 2014

“It’s time for a change in how we monitor postoperative patients receiving opioids,” declares Dr. Robert Stoelting, president of the Anesthesia Patient Safety Foundation (APSF). “We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”

The APSF recently released a video highlighting the conclusions and recommendations that came out of a 2011 conference on opioid-induced ventilatory impairment. You can find the video here.

In the video, APSF states that continuous electronic monitoring of oxygenation and ventilation, when combined with traditional nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment.

The clinical significance continuous electronic monitoring offers is the opportunity for prompt and predictable improvement in patient safety.

According to Lenore Alexander, founder and executive director of Leah’s Legacy, a patient safety organization focused on safe opioid use:

“A monitor would have saved my child’s life. I have made the goal of continuous postoperative monitoring my commitment.

“All that stands between us and universal post op monitoring is the will to require it.”

In the APSF video, health experts warned of the risks of selectively monitoring some patients.

According to Nikolaus Gravenstein, MD, Professor of Anesthesia, University of Florida School of Medicine, APSF Committee on Technology:

“Who should be monitored electronically? I would say any inpatient but certainly any inpatient prescribed narcotics, because if they are prescribed they can be received.”

According to Michael DeVita, MD, Critical Care Medicine, St. Vincent’s Hospital:

“You need to absolutely require a continuous monitoring system if it’s your goal to prevent every possible death. Who should be monitored? Everyone.”

Mark Montoney, MD, MBA, Executive Vice President and Chief Medical Officer, Vanguard Health Systems, also argued that the costs of continuous electronic monitoring should not be an impediment to saving patients’ lives:

“No matter where you set the thresholds, I think you get too many false negatives and false positives. We either get this sense of security that everything is all right, when in fact it may not be. Or, we have these alarms that are going off that eventually our caregivers get desensitized to.

“I would agree with the notion of continuous monitoring. I don’t see the value of intermittent monitoring. I really stop short at talking about high-risk patients because, while we can define them in a category, we’re going to get burned when we try to differentiate because you don’t always know who’s a high-risk patient.

“One of the questions that’s been asked is, ‘Boy, this is going to cost a lot, isn’t it?’ And I say, ‘Can we not afford to do this?’”

The Physician-Patient Alliance for Health and Safety (PPAHS) applauds the APSF for its goal to prevent every possible death and adverse event associated with opioid induced ventilatory impairment and PCA therapy.

Alarm Fatigue, Capnography, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

The Intertwined Stories of Amanda Abbiehl and Continuous Electronic Monitoring

In the recent article, “Silent Danger: PCA Pumps and the Case for Continuous Monitoring” published by Association for the Advancement of Medical Instrumentation in Biomedical Instrumentation & Technology, the story of 18-year old Amanda Abbiehl is told as a powerful reminder of the need for continuous electronic monitoring.

Amanda was admitted to hospital for “severe strep throat”, placed on a patient-controlled analgesia pump to manage her pain, and passed away – most likely because of opioid-induced respiratory depression.

In this slide share, this article has been adapted and retold.

The Physician-Patient Alliance for Health and Safety wishes you the best for this holiday season. Our New Year’s Resolution is to do everything we can to eliminate tragedies like Amanda’s. Join us in making a #promise to Amanda to achieve zero preventable deaths associated with opioid-respiratory depression at your hospital.

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

Continuous Electronic Monitoring Reduces Adverse Events and Hospital Expenditures: Physician-Patient Alliance for Health & Safety Awarded Permanente Journal Service Quality Award

The Physician-Patient for Health & Safety (PPAHS) is pleased to announce that its presentation on the national survey of hospitals on patient-controlled analgesia (PCA) hospital practices was awarded the Permanente Journal Service Quality Award. The award was presented December 10, 2013 at The 25th Annual IHI National Forum on Quality Improvement in Health Care.

For a pdf of the poster presentation, please PPAHS IHI Poster.

Respondents to the survey consisted of almost 200 hospitals from 40 states and provide a benchmark for measuring what hospitals are doing and not doing to ensure patient safety practices with PCA.

The survey is the first time that hospital practices regarding PCA have been surveyed nationally. Michael Wong, JD (Executive Director at the Physician-Patient Alliance for Health & Safety) says that the survey provides a benchmark of practices.

“The survey shows what hospitals are doing and not doing when initiating and continuing patients on PCA, which likely accounts for the adverse events and deaths related to PCA use” says Mr. Wong. “The survey found that hospitals across the country are not consistently assessing patients for risk factors. For example, almost one out of five hospitals are not assessing patients for being opioid naive, and about three out of 10 hospitals do not consider obesity as a patient risk factor, despite the indications of many studies that have shown the increased risk of using anesthesia with obese patients.”

Moreover, the survey also found that hospitals have been able to reduce adverse events, costs, and expenditures through continuous electronic monitoring of their patients.

“Hospitals that have implemented continuous electronic monitoring of patients are realizing tremendous patient safety benefits as a result,” says Mr. Wong. “In fact, 65 percent of the surveyed hospitals that electronically monitor said they have not only reduced incidences of respiratory depression and other adverse events significantly, but also lowered their post-surgical costs and expenses.  The remaining 35 percent stated that it was either too early to determine or that they have not yet determined what benefits they have derived from the technology.”

“Considering this positive finding of the survey,” says Frank Federico, RPh (Executive Director at the Institute for Healthcare Improvement and a member of the Patient Safety Advisory Group at The Joint Commission), “it seems obvious that hospitals that have not yet implemented continuous electronically monitoring of their patients on PCA would be wise to do so.  That’s not to suggest that continuous monitoring is a ‘silver bullet’ solution for reducing adverse events.  Clearly, the safe use of opioids is a multi-step process, and its success requires systemic collaboration within the hospitals that implement it.  However, the opportunity to reduce adverse events and death, and to decrease costs and expenditures is not only good for patients but for our healthcare system looking to achieve cost savings.

Alarm Fatigue, Capnography, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring

3 Questions About Patient Safety and PCA with Brian and Cindy Abbiehl from A Promise to Amanda Foundation

by Sean Power
December 12, 2013

The Physician-Patient Alliance for Health and Safety released their findings from the First National Survey on Patient-Controlled Analgesia (PCA) Safety Practices.

The report on the National Survey on Patient Safety with PCA is available to download for free here. It asked pharmacists, doctors, nurses, respiratory therapists, and administrators at hospitals from 40 states about their safety measures for PCA.

Brian and Cindy Abbiehl, founders of A Promise to Amanda Foundation (which co-sponsored the research), recently shared their thoughts on some of the findings on the patient risk factors being considered at hospitals during the administration of PCA.

The Abbiehls founded A Promise to Amanda Foundation to raise awareness about respiratory depression after the death of their 18 year-old daughter Amanda. Amanda was admitted to a hospital for an infection and was hooked up to a PCA pump to manage her pain. Less than twelve hours after Amanda was put on a PCA using Delaudid she was found unresponsive. Amanda’s parents believe that, had Amanda been monitored with capnography and pulse oximetry, nurses would have been alerted that she was in trouble and been able to intervene.

You can find a copy of the survey results here.

SP: The survey asked respondents about which risk factors they consider before patients initiate PCA. Was there anything in the results that surprised you?

Cindy Abbiehl: I don’t think we had any expectations going into the survey so I wouldn’t say we were surprised by any of the findings.

I think it’s more accurate to say that the results disappointed us in the sense that, for PCA to be administered safely, every risk factor included in the survey should be considered for every patient before initiating PCA. Not all hospitals consider every factor. That needs to change.

The risk factors include obesity, low body weight, concomitant medications that potentiate sedative effects of opiate PCA, pre-existing conditions such as asthma and sleep apnea, advanced age, and opioid naïve.

These risk factors were identified in the Physician-Patient Alliance’s PCA Safety Checklist last year, which was assembled by a number of well-respected health care professionals. The impact of not considering these risk factors can be tragic.

Brian Abbiehl: Cindy and I are talking from experience when we use the word “tragic.” Our daughter, Amanda, was administered PCA to manage pain despite Amanda being opioid naïve. The PCA survey reveals that around 1 in 5 hospitals do not consider whether the patient is opioid naïve before initiating PCA.

Checking if patients are opioid naïve will raise a red flag to health care providers and can prevent tragic outcomes. The Food and Drug Administration associated PCA with 56,000 adverse events and 700 patient deaths between 2005 and 2009. Considering all risk factors can help to prevent these tragic outcomes.

CA: The survey showed that non-pharmacists were about four times less likely than pharmacists to say that they consider opioid naïve as a patient risk factor. As the front line professionals interacting with patients, this reality needs to change. Pharmacists, physicians, nurses, respiratory therapists, and other health care professionals all need to be on the same page when administering PCA.

SP: You two have spoken about Amanda’s death many times in the past. What would you like to see come out of the findings of the survey?

BA: We’re hopeful that the survey will bring attention to the fact that PCA can be dangerous without the proper safety measures in place.

One of the survey’s key findings is that there exists a great lack of consistency in safety procedures being followed by hospitals across the country. Indicated by the survey are a number of safety recommendations for health care providers.

For instance, the survey provides a list of patient risk factors to consider when initiating PCA. It outlines when to perform double-checks, and what to double-check. It highlights the use of capnography, pulse oximetry, and “smart pumps” to keep patients safe. There are a number of other safety practices that can be followed.

CA: When you ask what we’d like to see from the survey, the ultimate answer is better patient outcomes. Safer care. Fewer adverse events. Zero preventable deaths associated with PCA.

Implementing some of the safety practices asked about in the survey, partnered with a culture of safety at hospitals in the United States, will save lives.

SP: Are there any safety practices you believe are particularly important for the administration of PCA?

CA: They’re all critical—especially those contained in the PCA Safety Checklist I mentioned earlier.

A Promise to Amanda Foundation focuses on the continuous electronic monitoring of all patients every time a patient is placed on a PCA pump, is sedated, requires a stay in the PACU following general anesthetic, or requires a stay in the PACU following sedation.

Continuously monitoring with capnography and pulse oximetry is key because it provides a technological safety net. For instance, “smart pumps” with forcing functions monitor trends in the quality of breath. Should these trends indicate that the patient is experiencing respiratory depression, it stops infusing medicine and alerts nurses to intervene.

Without smart pumps, the nurse might not be aware that the patient is experiencing respiratory depression until the nurse’s next “spot check”, which could occur as far as four hours from the time of respiratory depression at some hospitals.

For these reasons, A Promise to Amanda Foundation focuses on making continuous electronic monitoring mandatory in the administration of PCA. It enables health care professionals to prevent adverse events and clinically intervene.

Even if health care professionals miss a double-check, or fail to consider every risk factor, or overlook any other critical safety practice, capnography and pulse oximetry will help to prevent respiratory depression by notifying caregivers before the patient’s condition deteriorates to Code Blue levels.

BA: We understand that alarm fatigue continues to be a main obstacle to implementing the patient monitoring with capnography and pulse oximetry. The survey found that 9 out of 10 hospitals believe reducing false alarms would increase the use of such devices.

In addition to using capnography and pulse oximetry, then, we would insist that reducing the incidence of false alarms is a safety practice that is particularly important for safer PCA use.

The Joint Commission is expected to announce a National Patient Safety Goal on alarm management in 2014. We hope that health care professionals will rally behind them and make PCA safety a priority by improving alarm safety at their hospital.

Alarm Fatigue, Capnography, Infographics, Monitoring Liability and Costs, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA

INFOGRAPHIC: First National Survey of Patient-Controlled Analgesia Practices

INFOGRAPHIC: First National Survey of Patient-Controlled Analgesia Practices

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Capnography, Monitoring Liability and Costs, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring

New National Survey Finds Patient Safety at Risk Because of Lack of Consistency in Hospital Patient-Controlled Analgesia Practices

Inconsistency in safe practices most likely accounts for large proportion of adverse events and deaths associated with PCA use, says Physician-Patient Alliance for Health and Safety.

The Physician-Patient Alliance for Health and Safety today released the results from a national survey of United States hospitals on the administration of patient-controlled analgesia (PCA).

According to reports made to the Food and Drug Administration between 2005 and 2009, more than 56,000 adverse events and 700 patient deaths were linked to PCA pumps.

“A national survey of hospitals regarding PCA administration has never been conducted despite PCA pumps being linked to such a high number of adverse events and deaths,” says Michael Wong, JD, founder and executive director of the Physician-Patient Alliance.

“On the negative side, the survey reveals that there is a huge cause for concern for patient safety, as there is a great lack of consistency in safety procedures being followed by hospitals across the country,” says Mr. Wong. “This most likely accounts for a large proportion of adverse events and deaths associated with PCA use.”

Mr. Wong continues: “On the positive side, survey findings also show that adverse events have been averted or costs and expenses reduced by hospitals that are continuously monitoring their patients with pulse oximetry and/or capnography. This demonstrates the critical importance of using continuous monitoring as technological safety nets for patients. As well, it also points to a way hospitals may reduce their costs and expenses.”

A copy of the survey results is available for free on the Physician-Patient Alliance website here.