Tag: Patient-Controlled Analgesia

AORN Poster Presentation: Unrecognized Opioid Induced Respiratory Depression and PCA Safety Checklist

The Physician-Patient Alliance for Health & Safety (PPAHS) recently presented a poster presentation at the 60th Congress of the Association of Perioperative Registered Nurses (AORN).

This poster discussed the problem of opioid-induced respiratory depression, particularly regarding patient-controlled analgesia (PCA). As well, the presentation focused on the place of the recently released PCA Safety Checklist in addressing opioid warnings expressed by The Joint Commission in its Sentinel Event Alert of safe use of opioids in hospitals. Continue reading “AORN Poster Presentation: Unrecognized Opioid Induced Respiratory Depression and PCA Safety Checklist” →

Understanding Adverse Events and Death: Root Cause Analysis of California Department of Public Health Case

by Dr. Bradley Truax

(The Truax Group consults with hospitals to improve patient safety and procedures.)

PCA (Patient Controlled Analgesia) safety has been one of our most frequent topics. Serious incidents related to PCA continue to occur frequently. Another case with some valuable lessons learned comes from the California Department of Public Health (CDPH 2012). Continue reading “Understanding Adverse Events and Death: Root Cause Analysis of California Department of Public Health Case” →

First National Survey of Patient-Controlled Analgesia Practices

Physician-Patient Alliance for Health & Safety invites participation in the first national survey of patient-controlled analgesia practices.

If you are a physician, nurse, respiratory therapist, pharmacist, or other healthcare provider, to take part in this brief national survey on PCA practices (which is only open to healthcare providers), please visit https://www.surveymonkey.com/s/PCAhospitalsurvey

 

Physician-Patient Alliance for Health & Safety Supports Leah’s Law For Continuous Electronic Monitoring of All Post-Operative Patients Receiving Opioids

AOL recently did a video feature on Lenore Alexander’s appearance on the Katie Couric Show “Shocking Medical Mistakes”

AOL recounts Lenore’s discussion with Katie Couric that “Leah was not hooked up to any monitors” following her successful surgery to repair a condition called pectus carinatum or ‘pigeon’s chest’, a fairly common condition where the sternum protrudes forward caused by an overgrowth of cartilage. Continue reading “Physician-Patient Alliance for Health & Safety Supports Leah’s Law For Continuous Electronic Monitoring of All Post-Operative Patients Receiving Opioids” →

Third Leading Cause of Death is Preventable

Dr. Peter Pronovost (PhD, FCCM, Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient) recently appeared on the Katie Couric Show on “Shocking Medical Mistakes”.

On the Show, Dr. Pronovost discussed the number of preventable deaths that occur each year in the United States: Continue reading “Third Leading Cause of Death is Preventable” →

Update on CMS Proposed Quality Measure on PCA Patient Safety

We would like to thank all of those who submitted comments on the proposed quality measure being considered by CMS regarding the monitoring of patients using patient-controlled analgesia (PCA) pumps.

In the report submitted by the National Quality Forum to the United States Department of Health and Human Services, the measure was not endorsed and it was decided that the measure “requires modification or further development”. More particularly, the report provides: Continue reading “Update on CMS Proposed Quality Measure on PCA Patient Safety” →

Does CMS’ Proposed Quality Measure on Patient Monitoring Adequately Address Patient Safety?

by Michael Wong

(This article first appeared in Becker’s Clinical Quality & Infection Control.)

CMS is considering a proposed quality measure that would require “appropriate monitoring of patients receiving PCA [patient-controlled analgesia].” This measure seeks to address the high number of errors that occur with PCA, which unfortunately research shows happens all too frequently. Continue reading “Does CMS’ Proposed Quality Measure on Patient Monitoring Adequately Address Patient Safety?” →

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. Continue reading “Does CMS Proposed Measure for PCA Safety Go Far Enough?” →

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.” Continue reading “10 Reminders to Ensure Safer Use of Patient-Controlled Analgesia” →

PPAHS Presents at IHI Forum on How Patient Safety Checklist Helps Address Opioid Warnings from The Joint Commission

At the recent Institute for Healthcare Improvement (IHI) 24th Annual National Forum on Quality Improvement in Health Care.

The presentation focused on The Joint Commission Sentinel Event Alert on safe use of opioids in hospitals, which states:

“While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.”

Continue reading “PPAHS Presents at IHI Forum on How Patient Safety Checklist Helps Address Opioid Warnings from The Joint Commission” →