by Michael Wong
18-year old Amanda Abbiehl tragically died in 2010 at Saint Joseph Regional Medical Center (SJRMC).
The cause — a PCA (patient-controlled analgesia) pump error. As the petition filed with Indiana’s Patient Compensation Fund states:
“Against her treating physician’s orders, Amanda was given a constant dose of Hydromorphone once she was connected to the PCA pump … Amanda’s family, as well as SJRMC staff, have indicated it took several staff members a long time to program the pump.”
As Amanda’s father says:
“My wife and I believe in our hearts and minds that had there been a protocol in place requiring the use of a monitor … she would still be with us today.”
So, what does a class at University of Notre Dame do in the face of this tragedy?
The class is helping “design materials to convey their message to medical professionals as well as the general public”. According to their professor, Robert Sedlack, this project was inspired when the students heard about the death of Amanda.
To assist with this project, at the request of Amanda’s parents and Notre Dame’s class, the Physician-Patient Alliance for Health and Safety (PPAHS) and three other healthcare experts were invited to discuss PCA errors, the role of technology in improving patient safety (such as “smart” PCA pumps with integrated capnography being used at Veteran Health Administration and St. Joseph’s/Candler hospitals). (For a pdf of the PPAHS presentation, please here.)
So, here are two key questions that the class has:
- Who are the patient safety champions who would lead the charge in implementing smart PCA pumps at hospitals (e.g., anesthesiologists, nurses, respiratory therapists)?
- What information would these champions need to have to affect change in their organizations?
What do you think?