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”→
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?
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 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.”
The Society for Non OR Intervention and Anesthesia (SONORIA) and the Physician-Patient Alliance for Health & Safety (PPAHS) are pleased to announce their new alliance focused on promoting safety and optimized outcomes for patients undergoing procedures outside of the Operating Room. Wendy Gross MD, President of SONORIA and Michael Wong JD, CEO and Executive Director of PPAHS have each agreed to serve as advisors to their respective organization’s Boards.Continue reading “SONORIA and PPAHS Announce Alliance to Improve Clinical Collaboration”→
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.