Tyler’s Story: A Deadly PCA Medical Error

Tyler was 18-years old when he was admitted to hospital for a pain in his chest.

It was a collapsed lung – the second time he had experienced one that year, and a condition that tall, young, slim males like Tyler can be prone to. To permanently correct the problem, Tyler underwent a procedure called pleurodesis, a common procedure to permanently prevent his lung from collapsing again. Upon the successful completion of the surgery, Tyler’s mother, Victoria Ireland said that she “breathed a sigh of relief”. Her son was going to be OK; all he needed to do was recover.

In order to manage the pain from the operation, Tyler was placed on a patient-controlled analgesia (PCA) pump. A PCA pump delivers the amount of opioids prescribed by the doctor at intervals triggered by the patient using a button. The morning after being transferred to the general floor of the hospital for recovery, Tyler was found unresponsive. Dead in bed. Though the coroner officially ruled Tyler’s death as “sudden adult death syndrome”, there could be more to this story.

Tyler’s dosage of morphine was increased during his stay in hospital despite some disagreements by nurses on the floor. He was also not placed on continuous electronic monitors – such as pulse oximetry to measure oxygenation or capnography to measure the adequacy of ventilation – to detect the early signs of opioid-induced respiratory depression. Instead, nurses on shift made regular spot checks to monitor patients. As fate would have it, the nurse on shift that night had only completed half of the hospital-mandated one-day training session for the care of patients using a PCA pump. All of the clinicians responsible for Tyler’s care failed to notice that, after increasing the young man’s morphine dosage, he was lethargic, disoriented, and would snore very loudly during sleep: several signs of early-early onset opioid-induced respiratory depression.

Tyler’s story raises many questions.

What if his respiration vitals were monitored by continuous electronic monitors, such as capnography?

What if his pain management plan included non-opioid alternatives?

What if the nurse on shift that night had fully-completed the hospital’s PCA training?

What if a risk-assessment tool was used, such as STOPBang, to assess Tyler for complicating conditions such as obstructive sleep apnea?

Would Tyler still be alive? He could have been. And it’s up to us – clinicians, public health organizations, and patients – to ensure that medical errors such as these never occur again.

For clinicians touched by the story, PPAHS’ PCA Safety Checklist is a free downloadable tool and is just the first step to improving opioid safety. For concerned patients and family, here are 4 Essentials for PCA Safety from PPAHS.

Read Victoria Ireland’s full story of her son, Tyler, at TheDoctorWeighsIn here.

This video interview was shot by CareFusion. CareFusion has given permission to PPAHS to publish this video.

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