Tag: respiratory depression

Adverse Drug Events Discussed at California Hospital Engagement Network

by Sean Power

The Physician-Patient Alliance for Health & Safety recently participated in a webinar hosted through the California Hospital Engagement Network, an organization that brings together hospitals to reduce patient harm by 40% and readmissions by 20% by the end of 2013.

The panel discussion looked at patient stories and best practices for preventing opioid related adverse events. The panelists included: Continue reading “Adverse Drug Events Discussed at California Hospital Engagement Network” →

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” →

Addressing The Joint Commission Opioid Warnings: A Case Study from Wesley Medical Center on Reducing Respiratory Depression and Improving Patient Safety

By Sean Power and Michael Wong

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

Respiratory depression has been associated with the use of opioid analgesics. However, a recent study by researchers at Wesley Medical Center in Wichita, Kan., suggests exhaled CO₂monitoring of patients using patient-controlled analgesia pumps could help reduce the occurrence of this adverse event. Specifically, Debra Fox, MBA, RRT-NPS, and Mark Wencel, MD, examined respiratory depression rates with the use of PCA pumps and intermittent IV opioids for pain management. Continue reading “Addressing The Joint Commission Opioid Warnings: A Case Study from Wesley Medical Center on Reducing Respiratory Depression and Improving Patient Safety” →

Respiratory Depression: The Common Fatal Pathway for “Non Fatal” Conditions

Frank J Overdyk, MD¹, Marieke Niesters, MD², Albert Dahan, MD, PhD²

¹Hofstra North Shore-LIJ School of Medicine, ²Leiden University Medical Center

(These are excerpts of the poster presentation made at the recent annual meeting of the American Society of Anesthesiologists. It is reprinted with permission.)

Introduction

Preventable deaths in hospitals remain a major public health hazard worldwide. Analysis of registries for cardiopulmonary arrests (CPA) identified missed vital signs and symptoms of decompensation and spurred the development of RRT and MET teams. Although widely adopted, their impact on overall hospital morbidity and mortality remains unclear.

‘Alarm fatigue’, where poor ergonomics, integration and response to alarms on medical devices desensitizes providers to alarms was identified by the ECRI as the top health technology hazard for 2012, causing 500+ preventable deaths . The FDA, JC, AAMI, and ACCE have joined forces to remedy this patient safety hazard. Continue reading “Respiratory Depression: The Common Fatal Pathway for “Non Fatal” Conditions” →

Monitoring the High-Acuity Patient: Does Risk Stratification Increase or Decrease Patient Safety?

by Dr. Frank Overdyk (Executive Director for Research, North American Partners in Anesthesiology, and Professor of Anesthesiology at Hofstra University School of Medicine)

Summary: The topic of who is a suitable candidate for outpatient surgery is front and center with productivity pressures being intense at ambulatory surgery centers. However, with surgery often comes the necessity of the use of opioids for pain control. Studies have shown that any patient receiving opioids may be at risk of postoperative respiratory depression and if undetected, respiratory arrest (also known as “Code Blue”). The most common antecedents to cardiopulmonary arrest are of respiratory origin. Respiratory decompensation—as evidenced by tachypnea, bradypnea, hypoxia, hypercarbia or changes in mental status—are often the earliest warning signs of physiologic instability. Monitoring respiratory function and level of consciousness are especially important in detecting and preventing adverse events for patients receiving opioids and sedatives. Continue reading “Monitoring the High-Acuity Patient: Does Risk Stratification Increase or Decrease Patient Safety?” →

Errors with patient-controlled analgesia (PCA): just the tip of the iceberg

Reported errors with patient-controlled analgesia – estimated at between 600,000 to 2 million PCA errors each year – are just the tip of the iceberg.

by Michael Wong

Many readers emailed studies, suggestions, and comments regarding the estimate of 600,000 to 2 million PCA errors each year. These readers not only indicated the magnitude of the problem, but also a way to detect respiratory depression. Here are these further studies and thoughts. Continue reading “Errors with patient-controlled analgesia (PCA): just the tip of the iceberg” →

90% say all postoperative patients should be monitored

by Michael Wong

In the recent survey that we conducted, 90% of respondents believe that “continuous electronic monitoring of oxygenation and ventilation should be available and considered for all patients and would reduce the likelihood of unrecognized clinically significant opioid-induced depression of ventilation in the postoperative period.” Continue reading “90% say all postoperative patients should be monitored” →