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. Continue reading “Remembering Amanda: 7 Years After An Opioid-Related Death”
Tag: opioid pain management
In 2005, Paul Buisson, a celebrated Quebec animator and cameraman died as a result of opioid-related respiratory depression. What lessons can we learn more than a decade later? Continue reading “The Preventable Death of Paul Buisson: 3 Lessons on Preventing Opioid Death”
The following is a position statement published by PPAHS. If you would prefer to view our statement as a PDF, please click here.
Much of the public attention has been focused on the harm caused by prescription use and abuse of opioids. However, there is another facet that must be focused on: opioid-induced respiratory depression in clinical settings. This includes patients undergoing moderate and conscious sedation, or recovering from procedures and managing pain using a patient-controlled analgesia (PCA) pump, particularly those during the postoperative period. Continue reading “Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring”
Tyler was 18-years old when he was admitted to hospital for a pain in his chest.
It was a collapsed lung – the second time he had experienced one that year, and a condition that tall, young, slim males like Tyler can be prone to. To permanently correct the problem, Tyler underwent a procedure called pleurodesis, a common procedure to permanently prevent his lung from collapsing again. Upon the successful completion of the surgery, Tyler’s mother, Victoria Ireland said that she “breathed a sigh of relief”. Her son was going to be OK; all he needed to do was recover. Continue reading “Tyler’s Story: A Deadly PCA Medical Error”
The following is an excerpt of an article written by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety). It first appeared on Healthcare Business Today on April 9, 2017. To read the full article, please click here.
As the Executive Director of the Physician-Patient Alliance for Health & Safety, a non-profit whose mission is the improvement of patient safety, I am often asked how to tell a “good” hospital (i.e. patient safe) from a “bad” hospital (i.e. unsafe).
In thinking about “good” and “bad” hospital leadership, I am reminded of two discussions I had with hospital leaders – which leaders’ hospital would you rather be a patient at or, if you are a clinician, work at?
I spoke with the CEO of a hospital, who was dealing with the family of a child that had died within the hospital from opioid-induced respiratory depression. His clinicians had not employed continuous electronic monitoring with pulse oximetry for oxygenation or with capnography for adequacy of ventilation. Continue reading ““Good” Hospitals Require Real Leaders”
A recent article published by the American Association for Respiratory Care (AARC) has highlighted how respiratory therapists (RT) can play an integral role in using capnography to detect the signs of respiratory depression. The post focuses on the experiences of Peggy Lange, BA, RRT (RT Department Director, St. Cloud Hospital in St. Cloud, MN).
Over a three month period, St. Cloud Hospital ran a pilot program to test the effectiveness of continuous capnography monitoring Center for Surgical Care, PACU, surgical care units, interventional radiology, electrophysiology lab, and emergency trauma center. The trial was successful, proving the monitors gave an early alert to the signs of respiratory distress, as well as resolving issues caused by nuisance alarms – particularly with patients experiencing sleep apnea or periods of hyperventilation. As a result, continuous capnography monitoring was implemented hospital-wide. Continue reading “Minnesota RTs Help Implement Continuous Capnography Program”
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”
Opioid safety is one of the top patient safety concerns in the U.S.; with more than 2 million Americans dependent on opioids, opioid-related harm is an issue that has spans the continuum of clinical and public safety.
On August 25, 2016, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic. On the Surgeon General website, healthcare providers are encouraged to help solve the opioid epidemic.
The PPAHS conducted a survey to gauge how clinicians and the public felt about the Surgeon General’s recommendations to fight the opioid epidemic, with results released early November. Key aspects of the survey were recently featured in an article published by Advance for Nurses. The Advance Healthcare Network also distilled the survey’s top data points and recommendations. Continue reading “The U.S. Opioid Epidemic In Numbers”
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”
On August 25, 2016, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic. On the Surgeon General website, healthcare providers are encouraged to help solve the opioid epidemic:
“Our nation faces an opioid crisis. Health care providers are uniquely positioned to help communities and their patients #TurnTheTide on the opioid epidemic. Providers can be the solution. Join the movement. Sign the pledge.”
To gauge whether clinicians would answer this call and how clinicians and the public felt about the Surgeon General’s recommendations to fight the opioid epidemic, the Physician-Patient Alliance for Health & Safety (PPAHS) conducted a survey to examine perceptions about the Surgeon General’s appeal to physicians to play an active role in stemming the opioid epidemic. Continue reading “Physicians on Surgeon General’s Letter on Opioid Epidemic: Survey Results”