Opioid Safety, Respiratory Compromise

Top 10 Opioid Safety Articles in 2014

Of the more than 125 articles we posted in 2014, below are 10 of the most read and most discussed articles on opioid safety (order is by publication date).

As you read through these articles, please ask yourself – has a new standard of care been established requiring continuous electronic monitoring by hospitals of all patients receiving opioids? Read More

Respiratory Compromise

Medical standards of care and the Joan Rivers death

By Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), Frank Overdyk, MSEE, MD  (Professor of Anesthesiology, Hofstra North Shore-LIJ School of Medicine), Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety), Kenneth P. Rothfield, MD, MBA (Chairman of the Department of Anesthesiology at Ascension Health’s Saint Agnes Hospital, Baltimore; Adjunct Associate Professor of Nursing at the University of Maryland; soon assuming role of System Chief Medical Officer, St. Vincent’s Healthcare)

When medical tragedies occur, one of the very first questions asked by patients, families, the legal system, the press, and the public is: “were appropriate care standards met?” Read More

Blood Clots, Must Reads, Opioid Safety, Respiratory Compromise

Weekly Must Reads in Patient Safety (Oct 31, 2014)

Good news and bad news.

Yes, there have been other things going on in healthcare other than Ebola-mania … thanks @sacbee_news for this illustration putting Ebola in perspective:

ebola comic

The Good News

First, we’ll start with the good news, because most people love a celebration. Read More

Alarm Fatigue, Opioid Safety, Respiratory Compromise

For Improving Patient Safety and Reducing Nuisance Alarms, Evidence Points to Revising Default Settings

by Sean Power and Michael Wong

Alarm fatigue and nuisance alarms put patient safety at risk. The Joint Commission’s Sentinel Event Alert on alarm safety states that between 85 percent and 99 percent of alarm signals do not require clinical intervention — and these nuisance alarms desensitize clinicians. Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Woman’s Death After Knee Surgery Calls Attention to Need for Better Monitoring

by Sean Power

The recent death of Helen Bousquet after what is being described by her son, Brian Evans, as “a basic routine procedure” at a hospital 40 minutes north of Boston highlights the need for better monitoring of patients after surgery. Mr. Evans is accusing the hospital of criminal negligence, according to an exclusive interview with Valley Patriot, as a result of how his mother’s visit to the hospital was handled by staff. Read More

IARS 2013
Opioid Safety, Patient Stories, Respiratory Compromise

PPAHS Presents PCA Safety Checklist at IARS Annual Meeting

by Sean Power

The Physician-Patient Alliance for Health & Safety presented at the International Anesthesia Research Society’s Annual Meeting in San Diego, California to discuss the latest advances in research and best practices in anesthesia clinical care. For a handout version of the poster presentation, please click here.

In its August 2012 Sentinel Event Alert, The Joint Commission warned: Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Does CMS Proposed Measure for PCA Safety Go Far Enough?

by Michael Wong

(This article is reprinted with the permission of Patient Safety & Quality Healthcare (PSQH).)

This is the question that I have been asking myself ever since Centers for Medicare & Medicaid Services (CMS) recently announced proposed quality measures it is considering for adoption through rule making for the Medicare program. Read More

Alarm Fatigue, Opioid Safety, Respiratory Compromise

10 Reminders to Ensure Safer Use of Patient-Controlled Analgesia

PCA-related device events are three times as likely to result in injury or death. As Tim Ritter (Senior Patient Safety Analyst, Pennsylvania Patient Safety Authority) reminds us, “Over the six-year period from June 2004 to May 2010, data collected by Pennsylvania Patient Safety Authority revealed that there were approximately 4,500 reports associated with PCA pumps. Moreover, U.S. Food and Drug Administration’s (FDA) Manufacturer and User Device Experience (MAUDE) database demonstrates that PCA-related device events are three times as likely to result in injury or death as reports of device events involving general-purpose infusion pumps.” Read More

Alarm Fatigue, Opioid Safety, Respiratory Compromise

Respiratory Depression: The Common Fatal Pathway for “Non Fatal” Conditions

Frank J Overdyk, MD1, Marieke Niesters, MD2, Albert Dahan, MD, PhD2
1Hofstra North Shore-LIJ School of Medicine, 2Leiden University Medical Center

(These are excerpts of the poster presentation made at the recent annual meeting of the American Society of Anesthesiologists. It is reprinted with permission.)


Preventable deaths in hospitals remain a major public health hazard worldwide.  Analysis of registries for cardiopulmonary arrests (CPA) identified missed vital signs and symptoms of decompensation and spurred the development of RRT and MET teams. Although widely adopted, their impact on overall hospital morbidity and mortality remains unclear.

‘Alarm fatigue’, where poor ergonomics, integration and response to alarms on medical devices desensitizes providers to alarms was identified by the ECRI as the top health technology hazard for 2012, causing 500+ preventable deaths . The FDA, JC, AAMI, and ACCE have joined forces to remedy this patient safety hazard. Read More