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?”
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 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”
This year, St. Joseph’s/Candler Health System (SJ/C) celebrated 12 years free from opioid-related adverse events. The PPAHS had the pleasure of interviewing Harold Oglesby, RRT, Manager to uncover the SJ/C team’s learnings in implementing the quality improvement project.
From the inception of the project, continuous electronic monitoring with capnography has been a cornerstone technology to keeping patients at SJ/C safe. Mr. Oglesby and his team implemented a continuous monitoring program with capnography after identifying a need for reliable, early indication of patient decline in ventilation. Since the initial pilot, the monitors have shown tangible results:
“There was a couple of ‘aha’ moments when we saw that capnography giving us, sometimes an hour earlier, [indication] of a patient that was getting into distress.”
Effective implementation is crucial whenever new technology is introduced in a clinical setting. During our interview, Mr. Oglesby speaks to three key learnings to make continuous monitoring with capnography a success. Continue reading “Preventing Opioid-Related Adverse Events with Capnography”
The Physician-Patient Alliance for Health & Safety (PPAHS) recently interviewed Harold Oglesby RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJ/C).
Continue reading “12 Years of Event-Free Opioid Use”
The Physician-Patient Alliance for Health & Safety (PPAHS) had the pleasure of interviewing Thomas W. Frederickson, MD, FACP, SFHM, MBA – lead author of the Society of Hospital Medicine RADEO guide (“Reducing Adverse Drug Events Related to Opioids”). The guide is a comprehensive clinician manual created with the aim to decrease opioid-related adverse events in an inpatient setting.
In the first of this two-part interview, Dr. Frederickson discusses five key steps to identify and address patient conditions that pose a greater risk of respiratory depression. For readers that have yet to listen to the podcast, please click here; it’s an insightful interview relevant for any clinician working in quality improvement or directly with patients prescribed opioids.
In part two, interviewer Pat Iyer and Dr. Frederickson switches gears and focuses on monitoring issues associated with caring for at-risk patients. You can watch/listen to the interview below: Continue reading “5 Strategies to Keep Patients Safe When Receiving Opioids”
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”
This week, we refocused our attention on the subject of opioid safety. Recently, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic.
In addition to bringing our readers the most topical articles and news from PPAHS and the web, we’ve also created a brief (2 minute – 5 question) survey to understand reactions to the Surgeon General’s letter. Please take the time to complete it here.
Continue reading “Patient Safety Weekly Must Reads (September 9, 2016)”