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 (http://promisetoamanda.org/amandas-storye 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.