Promoting patient safety and improving the quality of patient care
Tag: medical errors
If the federal government decided that the nation’s automakers were no longer required to publicly announce recalls of cars equipped with life-threatening defects, the protest from the masses would be deafening.
Yet, a similar scenario is playing out now in the nation’s healthcare industry with relatively little public outcry. Continue reading “CMS non-disclosure of medical errors indicates need for change in how healthcare performance is measured, reported in U.S.”
By Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (Baltimore, MD), Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety), and Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)
It is often said that a death is meaningful if it serves as lessons for others to learn from and increase awareness so they “speak up” when found in a similar situation. So, what can be learned from the death of Joan Rivers? Continue reading “4 Lessons Learned from the Death of Joan Rivers”
By Lenore Alexander (Executive Director, leahslegacy.org)
The mother of Leah Coufal, Lenore Alexander is Executive Director of Leah’s Legacy, a non-profit advocate for mandatory electronic monitoring of patients on opioids. She may be reached at lalexander@leahslegacy.org
(The article was first published in HealthCareReport.)
Eleven years ago, I found my 11-year-old daughter, Leah, dead next to me in her hospital bed. And though I haven’t spent this time attending medical school, I now have a much better understanding of what happened during the 30 hours my child was in the hospital’s care. It’s what’s come to be called a “perfect storm” – a cascade of mistakes and miscommunication. Continue reading “Continuous Electronic Monitoring Could Have Saved My Child, My Family, My Marriage and My Life: A 11-Year Reflection on a Medical Travesty”
by Pat Iyer, president of www.avoidmedicalerrors.com
Patient Controlled Analgesia (PCA) pumps were developed to address the problem of undermedication. They are used to permit the patient to self-administer small doses of narcotics (usually Morphine, Dilaudid, Demerol, or Fentanyl) into the blood or spinal fluid at frequent intervals. PCA pumps are commonly used after surgery to provide a more effective method of pain control than periodic injections of narcotics. This method of pain control has been found to result in less pain and earlier discharge from the hospital. PCA pumps can be effectively used by children as young as six years old. A continuous infusion (called a basal rate) of 1-2 mg/hour permits the patient to receive a continuous infusion of pain medication. This mode of delivery is now used only for patients who have had prior opioid use or are not “opioid naïve”. The risk of respiratory depression is too great in patients who have not built up a tolerance to opioids. Typically the patient receives an intravenous “loading” dose to quickly raise the blood level of the pain medication.
Continue reading “Patient Controlled Analgesia (PCA) Pumps: The Basics”
Reported errors with patient-controlled analgesia – estimated at between 600,000 to 2 million PCA errors each year – are just the tip of the iceberg.
by Michael Wong
Many readers emailed studies, suggestions, and comments regarding the estimate of 600,000 to 2 million PCA errors each year. These readers not only indicated the magnitude of the problem, but also a way to detect respiratory depression. Here are these further studies and thoughts. Continue reading “Errors with patient-controlled analgesia (PCA): just the tip of the iceberg”