Opioid Safety, Patient Safety, Respiratory Compromise

Was the Death of Erik Nelson of Preventable?

By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety)

According to the Bozeman Daily Chroncle’s article, “Wrongful death lawsuit filed against Bozeman surgeon,” Erik Nelson underwent surgery to correct his chronic nasal obstruction and severe obstructive sleep apnea. Discharged the day after surgery, Mr, Nelson was sent home with a prescription of Oxycodone to manage his pain. Oxycodone is a semisynthetic opioid, which is prescribed for moderate to severe pain.

Mr. Nelson took his prescription for Oxycodone the evening of his discharge and the following morning. As reported by the Chronicle, he “was found unconscious in his home by his partner. He was transported to Bozeman Health Deaconess Hospital, where he was later pronounced dead. The cause of death was respiratory failure in combination with postoperative swelling, according to the suit.”

After taking Oxycodone #opioid, Erik Nelson was found unconscious and later died - preventable?… Click To Tweet

Since I founded the Physician-Patient Alliance for Health & Safety (PPAHS) in 2011, I have the unfortunate role of speaking with grieving families, who often think that the deaths of their loved ones are isolated events. Tragically, adverse events and deaths from opioids are not isolated events, even when done under the direction and prescription of a physician.

Adverse events and deaths from #opioids are not isolated events, even when done under the direction… Click To Tweet

In August 8, 2012, The Joint Commission issued Sentinel Event #49, “Safe use of opioids in hospitals.” The Joint Commission issues Sentinel Event Alerts “because they signal the need for immediate investigation and response.” In Sentinel Event Alert #49, The Joint Commission cautions:

“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.”

Despite this warning by The Joint Commission in 2012, unfortunately patient deaths and adverse events from physician-prescribed opioids continue. In just the last two weeks, I have written about brain damage suffered by five-year old Amber Athwal after undergoing dental treatment and the more than $3.2 million malpractice judgement in the death of Lorrie McCombs. In both of those instances, an opioid analgesic was administered, but the patient was not monitored as recommended by the American Society of Anesthesiologists (ASA).

The ASA sets the standards for the medical practice of anesthesiology. According to the ASA’s Standards for Basic Anesthetic Monitoring:

“During all anesthetics, the patient’s oxygenation, ventilation, circulation, and temperature shall be continually evaluated.”

In the case of Erik Nelson, he was administered Oxycodone and the lawsuit says that Oxycodone “is known to cause respiratory depression”and that his attending surgeon “‘deviated from accepted standards of medical care’ by failing to obtain Nelson’s medical history, neglecting to consult with his previous physicians or properly oversee his post-op care.”

Did Mr. Nelson’s physician deviate from the ASA Standards for Basic Anesthetic Monitoring?

In an article in ADVANCE for Nurses, Pamela Parker, BSN, RN, CAPA discusses lessons that she learned on the untimely death of her teenage son, Logan:

On July 23, 2007, my 17-year old son Logan died after successfully undergoing routine surgery to correct his sleep apnea. As a recovery room nurse, I have often asked myself how this could have been prevented.

By writing these six lessons I learned, I hope that other loved ones may be saved, other families spared the agony of losing a cherished member.

Pamela’s six lessons are:

Lesson #1 – All Patients Receiving Opioids Should be Assessed for Risk for Over-sedation and Respiratory Depression

Lesson #2 – Clinicians Must Recognize the Signs of Respiratory Compromise

Lesson #3 – All Patients Receiving Opioids Should be Continuously Electronically Monitored

Lesson #4 – Don’t Rely Upon Pulse Oximeters, Monitor with Capnography

Lesson #5 – All Patients Should be Monitored for an Extended Period in an Unstimulated Environment Prior to Discharge

Lesson #6 – Medical Interventions Shouldn’t be Based on Human Heroics, but on Process

Lesson #5 – All Patients Should be Monitored for an Extended Period in an Unstimulated Environment… Click To TweetTo listen to a podcast interview with nurse Parker, please click here.

Did the actions by the physician for Erik Nelson reflect nurse Parker’s lessons and the ASA Standards for Basic Anesthetic Monitoring? What do you think?Did the actions by Erik Nelson's physician reflect the ASA Standards for Basic Anesthetic Monitoring?… Click To Tweet

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