Amanda was 18-years-old when she was admitted to hospital for a severe case of strep throat. To help her manage the pain, she was placed on a patient-controlled analgesia (PCA) pump. The next morning, she was found unresponsive and died. Though PCA pumps are designed to deliver an exact dosage of opioid – in Amanda’s case, hydromorphone – getting the ‘right’ dosage is not a simple task. Too high a dosage can lead to respiratory depression, sometimes in minutes.
Unfortunately, undetected opioid-induced respiratory depression has remained in ECRI’s Top 10 Health Technology Hazards for years. Amanda’s death, and countless others, could have been prevented with the right technology and processes in place. In memory of her passing, the PPAHS would like to share, once again, how clinicians can prevent opioid-related harm:
1. Employ continuous electronic monitoring
Intermittent spot checks are not sufficient to detect the signs of opioid-related respiratory depression in time to intervene. All patients receiving opioids should be monitored using a combination of pulse oximetry and capnography.
To learn more, read PPAHS’ position on the need for continuous electronic monitoring here.
2. Use the PPAHS PCA Safety Checklist
With the goal of helping to reduce adverse events and deaths with PCA pumps, the Physician-Patient Alliance for Health & Safety (PPAHS) recently released a safety checklist that reminds caregivers of the essential steps needed to be taken to initiate PCA with a patient, and to continue to assess that patient’s use of PCA. This checklist was developed after consultation with a group of 19 renowned health experts.
The checklist is a free PDF download available here.
3. Visit the Promise To Amanda Foundation
The Promise To Amanda Foundation was created as a powerful reminder of the need for PCA monitoring. Says Cindy and Brian Abbiehl, Amanda’s parents:
“We created our foundation to honor the memory of Amanda and to ensure that other parents never experience the preventable death of their child, and that others never experience the preventable death of a loved one who has been placed on a PCA pump.”
Read more about Amanda’s Story, and how you can prevent opioid-related respiratory depression, by visiting the Promise to Amanda site here.
To learn more, watch and share our interview with Cindy and Brian Abbhiel: