By Michael Wong, JD (Founder/Executive Director, Physician-Patient Alliance for Health & Safety)
The Exception to the “Everything in a Box is Safe” Rule
In today’s world of science and engineering, we have a natural tendency to assume that, if it’s been engineered and it’s “in a box”, it must be ok and safe. While this may usually be true, there are exceptions to every rule. According to the FDA (Food & Drug Administration), more than 80,000 deaths and 1.7 million injuries have been linked to medical devices in the past decade.
One exception to the “everything in a box is safe” rule may be particularly true of a medical device called patient-controlled analgesia (PCA) pump, which when not paired with continuous monitoring may be deadly.
Researchers at the University of Colorado Hospital recently reported that their use of a PCA safety checklist was found to reduce pain from moderate-severe pain to no-mild pain in 42% of patients within 2 days. In “Let’s Be Smart About Improving Pain,” they reported:
Our PCA safety checklist smart phrases increased use of a safety checklist and documentation of daily PCA opioid trends, and correlated with more rapid improvement in moderate-severe pain levels.
A transfer of care can result in a medical error. In this joint article between the Canadian Patient Safety Institute and the Physician-Patient Alliance for Health & Safety, Michael Wong, JD (Founder & Executive Director of the Physician-Patient Alliance for Health & Safety) and Stephen Routledge, MPH (Patient Safety Improvement Lead, Canadian Patient Safety Institute) discuss how medical errors during transfers of care can be prevented.
In particular, two key resources are referred to in the article.
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.
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”→
“I’m going to have surgery soon and I have been told I will be given an opioid medication to control the pain after the operation. But I see stories of people getting hooked on opioids all over the news, and I’m scared to take them. Am I right to be worried?”
Paul Taylor, patient navigation advisor at Sunnybrook Health Sciences Centre in Toronto, recently fielded this question in a special to the Globe and Mail. The answer recommended that concerns about opioids be “kept in perspective” and that they can be extremely useful in managing short-term pain, noting that “problems can arise when patients end up on the drugs for longer than is necessary.” The addictive properties of opioids are indeed reason for concern.
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”→
The Physician-Patient Alliance for Health & Safety (PPAHS) has released a YouTube video which discusses in nine minutes how to improve opioid safety. The video features highlights from over 10 hours of in-depth interviews released by PPAHS in 2016; altogether, the podcast series has generated over 130,000 cumulative views on YouTube. The podcast series brings together physicians, nurses, and respiratory therapists discussing how they have improved opioid safety in their hospitals.
According to Michael Wong, JD, Founder and Executive Director of PPAHS:
“In just nine minutes, the video summarizes experiences of clinicians in improving opioid safety in their hospital or healthcare facility, and reminds us of the tragic consequences of adverse events and deaths that may ensue if clinicians and healthcare executives are not proactive in promoting safety. We hope that the video will energize quality improvement and patient safety teams to strive to reduce adverse events and deaths related to opioid use.”