Tag: opioid

Capnography Monitoring During Conscious Sedation:

The Physician-Physician Alliance for Health Safety has released a clinical education podcast on capnography monitoring during conscious sedation with Barbara McArthur, RN, BScN, CPN(C). Ms. McArthur is an advanced practice nurse at Sunnybrook Health Sciences Centre in Toronto, Canada.

Capnography Monitoring: An Early Indicator of Patient Deterioration

After reviewing the current literature, Sunnybrook decided that monitoring with capnography resulted in safer patient care. Capnography monitoring provides an early indicator of patient deterioration, which can be crucial in averting adverse events and patient deaths. Capnography monitoring, says Ms. McArthur, is monitoring in “real time. With pulse oximetry, there is a delay, which could be up to a minute in healthy patients. So, that’s a significant sort of time that is delayed that reaction could happen.” 

 

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Opioids Can Cause Adverse Events and Patient Deaths: ECRI Institute Patient Safety Organization’s Deep Dive Analysis

Despite the focus on appropriate use of opioids for pain management, ECRI Institute Patient Safety Organization (PSO) found that there are many hospitals that continue to experience opioid-related adverse events and deaths. To help prevent further patient harms and deaths, PSO conducted a deep dive analysis of adverse events related to opioids in the acute care setting.

Continue reading “Opioids Can Cause Adverse Events and Patient Deaths: ECRI Institute Patient Safety Organization’s Deep Dive Analysis” →

Was the Death of Erik Nelson Preventable?

By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety)

According to the Bozeman Daily Chroncle’s article, “Wrongful death lawsuit filed against Bozeman surgeon,” Erik Nelson underwent surgery to correct his chronic nasal obstruction and severe obstructive sleep apnea. Discharged the day after surgery, Mr, Nelson was sent home with a prescription of Oxycodone to manage his pain. Oxycodone is a semisynthetic opioid, which is prescribed for moderate to severe pain.

Continue reading “Was the Death of Erik Nelson Preventable?” →

Are Patients Receiving Opioids Safer Today Than 6 Years Ago?

Six years ago on July 27, 2011, I posted the first article on a free WordPress blog for the Physician-Patient Alliance for Health & Safety. It was titled “Is it possible to survive 96-minutes without a heart beat?”. Howard Snitzer, a man who suffered a heart attack survived after two volunteer paramedics responded and began a 96-minute CPR marathon. The ordeal involved 20 others, who took turns pumping his chest. This life-saving feat was only possible with the use of capnography readings, which told the volunteer paramedics that Howard was still alive and that they needed to continue their efforts.

Little would I know that that article would lead to an invitation by the University of Notre Dame and the beginnings of a 6-year friendship with the parents of Amanda Abbiehl. Amanda was admitted to hospital for “severe strep throat.” Continue reading “Are Patients Receiving Opioids Safer Today Than 6 Years Ago?” →

Remembering Amanda: 7 Years After An Opioid-Related Death

This weekend marked the 7th anniversary of Amanda Abbiehl’s tragic death. Her story continues to remind us of the need for continuous electronic monitoring for all patients receiving opioids.

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” →

The Preventable Death of Paul Buisson: 3 Lessons on Preventing Opioid Death

The following is an excerpt of an article first published on The Doctor Weighs In on June 28, 2017. To read the full article, please click here.

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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” →

Patient Safety Weekly Must Reads (June 3, 2017)

This week’s must reads focus on patient safety tools.

This week in #patientsafety, PPAHS announced our position that all patients receiving opioids must be monitored with capnography. From around the web, the American Journal of Nursing summarized venous thromboembolism (blood clots) guidelines from American College of Chest Physicians, Ontario released a dataset and tool to explore opioid-related morbidity and mortality, and Pain Medicine News discussed a researcher’s exploration of alternatives to opioids. Continue reading “Patient Safety Weekly Must Reads (June 3, 2017)” →

Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring

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” →

Anesthesiology Standards Shouldn’t be Different in Hospital and Outpatient Settings

Written by Lynn Razzano RN, MSN, ONC-C (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety).

When preventable medical errors 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?”. As a professional Registered Nurse, I look at this question from a quality and patient safety perspective to ask what could have been done differently? What are the best practice medical standards, and why are they not applied across the US health care systems? How applicable should the medical standard of care be? And how do we, as clinicians and patient advocates, define the best practice standard of care?

The reality is that the definition of best practice and standard of care differs between acute care hospital settings and outpatient surgery centers. And, even then, the standard of care being applied by the ambulatory surgical center, anesthesiologist and the gastroenterologist may not be the same. Continue reading “Anesthesiology Standards Shouldn’t be Different in Hospital and Outpatient Settings” →

Tyler’s Story: A Deadly PCA Medical Error

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” →