What lessons can we learn from the recently settled medical malpractice lawsuit against the clinic where Joan Rivers died days after undergoing a routine endoscopy? Continue reading “Highlights From Joan Rivers’ Death and Lawsuit”
Category: Patient Stories
Opioid Deaths Are (Still) Preventable: Remembering Leah
Leah walked into a Los Angeles hospital a healthy, 11-year old girl. She needed an elective surgery to repair a condition called pectus carinatum. Despite delays, the surgery went well, but Leah was in considerable pain; to manage it, she was given escalating doses of fentanyl, along with Ativan.
Her mother, Lenore Alexander, was concerned by Leah’s increasing unresponsiveness – but was assured by staff that Leah would be ready to walk out of the hospital in the morning. Exhausted, Lenore took a nap by her daughter’s bedside; it would be the last time Leah was seen alive. Lenore woke to find Leah dead in bed.
In 2012, Lenore wrote an article for PPAHS asking if continuous monitoring would have saved her daughter, Leah. The answer, then, was a resounding “yes”. During her hospital stay, Leah received only infrequent spot checks from staff to confirm her condition despite the administration of powerful opioids. If only she were monitored with capnography and pulse oximetry – we would not have another tragic story to tell.
Now, on the 14th anniversary of Leah’s death, we ask the same question: would continous monitoring have saved Leah’s life? Continue reading “Opioid Deaths Are (Still) Preventable: Remembering Leah”
Pamela Parker: My Son Did Not Have to Die
Pamela Parker BSN, RN, CAPA, has recently published a new article in Outpatient Surgery Magazine detailing her experiences losing her own son, Logan, to opioid-related hypoxia. Continue reading “Pamela Parker: My Son Did Not Have to Die”
5 Key Resources to Reduce the Risk of Respiratory Compromise with Patients with Sleep Apnea
In a recent interview with a spotlight on the RADEO guide, Dr. Thomas Frederickson, MD, FACP, SFHM, MBA highlighted obstructive sleep apnea (OSA) as a key contributing condition to greater opioid use risk.
“Sleep apnea is the number one risk factor for respiratory depression associated with the use of opioids.
[…] Patients with obstructive sleep apnea are dependent upon their arousal mechanism in order to avoid respiratory depression and eventual respiratory failure.”
In addition to being the #1 contributing risk to opioid-induced respiratory depression, OSA is also common and often under diagnosed. Dr. Frederickson states that between 7% and 22% of the adult population has a degree of sleep apnea.
The key question that arises, then, is how to better identify and account for OSA in patients receiving opioids? Here are 5 key resources to reduce the risk of respiratory compromise in this group. Continue reading “5 Key Resources to Reduce the Risk of Respiratory Compromise with Patients with Sleep Apnea”
How much safer are we? – Weekly Must Reads in Patient Safety (Jan 29, 2016)
In a recent article, Peter Pronovost, MD, PhD, FCCM (Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient; Member of the Physician-Patient Alliance for Health & Safety PCA Safety Panel and OB VTE Recommendations Working Group) asks a great question, “Patient Safety at 15: How Much Have We Grown?”.
Dr. Pronovost reflects on the past 15 years:
Continue reading “How much safer are we? – Weekly Must Reads in Patient Safety (Jan 29, 2016)”
Weekly Must-Reads in Patient Safety and Health Care (November 6, 2015) – When False Alarms Pollute Intensive Care
We have plenty of patient safety articles to share with you this week. From advice for nurses on how to educate patients about opioid diversion to tips for preventing medical errors in long-term care, audiences across the health care spectrum will benefit from some weekend reading.
Continue reading “Weekly Must-Reads in Patient Safety and Health Care (November 6, 2015) – When False Alarms Pollute Intensive Care”
Physician-Patient Alliance for Health & Safety Turns 4 Years Old
The Physician-Patient Alliance for Health & Safety (PPAHS) today celebrates its fourth anniversary.
PPAHS posted its first blog on July 27, 2011, “Is it possible to survive 96-minutes without a heart beat?”.
This post featured what happened to Howard Snitzer, who suffered a heart attack outside of a grocery store in Goodhue, Minnesota. Two volunteer paramedics responded and began a 96-minute CPR marathon involving 20 others, who took turns pumping his chest. Continue reading “Physician-Patient Alliance for Health & Safety Turns 4 Years Old”
Six Nursing Lessons: Nurse and Mother Reflects on the Untimely Death of Her Teenage Son
In an article in ADVANCE for Nurses, Pamela Parker, BSN, RN, CAPA discusses lessons that she learned on the timely death of her teenage son, Logan:
On July 23, 2007, my 17-year old son Logan died after successfully undergoing routine surgery to correct his sleep apnea. As a recovery room nurse, I have often asked myself how this could have been prevented.
By writing these six lessons I learned, I hope that other loved ones may be saved, other families spared the agony of losing a cherished member.
Anesthesiologists and Colonoscopies: A Lesson in Better Physician-Patient Relationships
By Patricia Iyer MSN RN LNCC
(Pat is a legal nurse consultant who provides education to healthcare providers about patient safety. She can be reached at patriciaiyer@gmail.com)
I went to see a gastroenterologist (Doctor A) because I am due for a colonoscopy. I had a colonoscopy done 4 years ago by a different doctor (Doctor B), and one closer to home. Doctor A wanted to know why I had not returned to Doctor B for this new one. I explained Doctor B and I had not clicked. This is what happened, and it is a good lesson for what not to say or do to a patient. Continue reading “Anesthesiologists and Colonoscopies: A Lesson in Better Physician-Patient Relationships”
Weekly Must Reads in Patient Safety (Feb 6, 2015)
While the Patient Safety, Science & Technology Summit called for “orders of magnitude” change, the story of Amber Scott, a mother who slipped into a coma during delivery, illuminates why improving safety for even a single person matters. Continue reading “Weekly Must Reads in Patient Safety (Feb 6, 2015)”