Editor’s note: In this article, Physician-Patient Alliance for Health & Safety executive director, Michael Wong, reflects on how the deaths of 18-year old Amanda Abbiehl set him on the path to becoming a patient safety advocate and up-coming research that PPAHS will be undertaking.
By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety)
Death From Patient-Controlled Analgesia
10 years ago today, 18-year old Amanda Abbiehl tragically died in 2010 at Saint Joseph Regional Medical Center (SJRMC).
The cause — a PCA (patient-controlled analgesia) pump error. As the petition filed with Indiana’s Patient Compensation Fund states:
“Against her treating physician’s orders, Amanda was given a constant dose of Hydromorphone once she was connected to the PCA pump … Amanda’s family, as well as SJRMC staff, have indicated it took several staff members a long time to program the pump.”
As Amanda’s parents write on the website “A Promise to Amanda” that they created in honor of their daughter:
“Amanda was on a general care floor and was not on any kind of electronic monitoring that might have alerted staff to her deteriorating condition.
“Would capnography monitoring have alerted Amanda’s nurses that she was experiencing respiratory depression that night?
“We have come to understand that continuous monitoring is not standard protocol outside of operating rooms. We encourage all healthcare facilities to monitor with oximetry and capnography to eliminate the possibility of respiratory depression as a cause of death.”
So, what does a class at the University of Notre Dame do in the face of this tragedy?
The class helped “design materials to convey their message to medical professionals as well as the general public”. According to their professor, Robert Sedlack, this project was inspired when the students heard about the death of Amanda.
To assist with this project, at the request of Amanda’s parents and Notre Dame’s class, three other healthcare experts and I were invited to discuss PCA errors, the role of technology in improving patient safety (such as “smart” PCA pumps with integrated capnography being used at Veteran Health Administration and St. Joseph’s/Candler hospitals). (For a pdf of the PPAHS presentation, please here.)
And, with that invitation and meeting my life as a patient safety advocate began.
Along the way, I have tried to raise awareness to increase the use of continuous electronic monitoring for all patients in-hospital who are prescribed an opioid. My journey as a patient safety advocate has resulted in innumerable:
- Conference presentations and speaking engagements at annual conferences of major medical organizations, such as the International Anesthesia Research Society, STA, Association of Perioperative Registered Nurses, and Society of Anesthesia and Sleep Medicine.
- Articles written for publications like Anesthesia News, Patient Safety Monitor, DoctorWeighsIn, and Becker’s Clinical Quality & Infection Control.
- Convening expert panels, such as the one that developed the PCA Safety Checklist.
Oxygen Saturation Research
To continue that awareness building, the Physician-Patient Alliance for Health & Safety has enlisted the help of Dr. Adam Bright. Dr. Adam S. Bright is an orthopedic surgeon in Sarasota, Florida. He has been in practice for more than 20 years and is the former President of the Florida Orthopedic Society. Dr. Bright proudly serves patients in Sarasota, Venice, Bradenton, and North Port. He offers a full range of orthopaedic treatment options, including joint replacement, sports medicine, and fracture and trauma care. Dr. Bright prides himself on seeing all of his patients himself (no physician extenders!) and performing all of his surgeries himself.
According to the Anesthesia Patient Safety Foundation, postoperative opioid-induced respiratory depression is a major in-patient safety concern, as shown by frequent and prolonged periods of desaturations. However, it is not known how often oxygen desaturation occurs following outpatient surgery or patients discharged home after a 24 hour patient stay, which is becoming increasingly common for orthopedic procedures such as total joint replacement.
To help further our understanding of what happens to a patient’s oxygen saturation level when they are discharged home with a narcotic, our study with Dr. Bright will evaluate prospectively the incidence of oxygen desaturation and bradypnea following outpatient orthopedic surgery – and to demonstrate the value and need for monitoring patients discharged to the home with an opioid.