At the recent Institute for Healthcare Improvement (IHI) 24th Annual National Forum on Quality Improvement in Health Care.
The presentation focused on The Joint Commission Sentinel Event Alert on safe use of opioids in hospitals, which states:
“While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.”
As a reminder of the human toll for not heeding The Joint Commission alert, PPAHS presented the “Faces of Tragedy”:
To assist in reducing and hopefully eliminate future tragedies, PPAHS recently released and presented its safety 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:
Commenting on the need for better health outcomes and the PCA Safety Checklist, Frank Federico, RPh (Patient Safety Advisory Group at The Joint Commission and executive director at the Institute for Healthcare Improvement) said:
“Use and adherence with standardized processes for eligible patients leads to better clinical outcomes. The PPAHS PCA checklist lays out essential steps to be taken to initiate patient-controlled analgesia (PCA) with a patient and to continue to assess that patient’s use of PCA. Following these steps will help to increase patient safety and save lives.”
What are you doing to address The Joint Commission Sentinel Event Alert on safe use of opioids in hospitals?
President Obama made a very powerful speech this past week in connecticut. His message was, if we cant protect our children, we are failing. How many children will be found Dead in Bed this holiday season, because our country can’t pass a simple law. Continuously monitor a child receiving narcotics.?
There is no longer any excuse.
During the IHI Forum, a picture of a young man was sent to us who recently died while on a PCA pump. CMS is considering a quality measure that for “All patient admissions with initiation of an opioid via an IV PCA device that is active for more than 2.5 continuous hours” that these patients be monitored for “respiratory rate, sedation score and pulse oximetry”. APSF recommendations go further — continuous electronic monitoring with capnography and oximetry — and PPAHS encourages CMS to amend its proposed quality measure to include APSF recommendations. For more, please see http://wp.me/p1JikT-q5
Keep pushing, PPAHS! This rule is so important – and needs to go further – to include remote monitoring, for instance, as it becomes possible and advantageous to provide care in a variety of out-patient settings…