Matt Whitman Letter on “My Near Miss”

by Matt Whitman, Retired Michigan State Trooper

In her recent op-ed article “My Near Miss” (New York Times Op-Ed, May 28), Dr. Danielle Ofri makes several convincing points about what caregivers should do to address one of the most important issues in their profession:  medical errors.  After reading it, I felt compelled to share my story.

As Dr. Ofri states, the difference between harm and safety is often a matter of “sheer luck.”  That was exactly the case for me after I underwent surgery on my neck, which had been injured several years earlier when a drunk driver collided with my squad car.

While in recovery, I was placed on patient-controlled analgesia (in my case, it was a morphine pump) to help manage my pain.  Though I know it very well now, I wasn’t aware at the time that PCA poses a risk for respiratory depression, which can lead to serious medical consequences, even death.

The night after my surgery, I experienced respiratory depression and stopped breathing.  I was, as they say, literally at death’s door.  But by sheer luck, an observant nurse just happened to walk by my hospital room after my breathing had stopped.  She immediately called a “Code Blue,” and that ultimately saved my life.

Like the patient Dr. Ofri so candidly describes in her article, I was a “near miss.”  And if not for the grace of God, I would not be alive today.

Yet, far too many patients on PCA have not been as fortunate as me. Tragic stories like those of 18-year-old Amanda Abbiehl ( t/) make that heartbreakingly clear.

Even more heartbreaking is the fact Amanda’s death could have been prevented.   The painfully sad truth is that had a technology safety net — continuous electronic monitoring of her PCA pump — been in place, Amanda would still be with us.

Dr. Ofri is absolutely correct that the culture of shame that surrounds medical errors can’t be easily solved with a “quality-improvement initiative or a zippy slogan.”  Yet, I strongly believe that safety net offered by technology could go a long way in reducing the millions of “near miss” cases that continue to cause caregivers so much shame.

3 thoughts on “Matt Whitman Letter on “My Near Miss”

  1. This nurse was a hero. And unfortunately, although we have the best technology in our hospitals, we are number 46 in the world, in health care, for exactly that reason. We depend on heroes, not the safety nets we have , already in place, in our hospitals. Until continuous monitoring is the standard of care for all patients on opioids ” dead in bed ” will continue to be on the list of never events, happening 20-50 times a month in some hospitals. This must become the standard of care, continuous monitoring for all patients on opioids.

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