Patient Safety

5 Lessons Learned from the Joan Rivers Death Settlement

By Frank Overdyk, MSEE, MD (Staff Anesthesiologist, Roper St. Francis), Kenneth P. Rothfield, MD, MBA, CPE, CPPS (System Vice President, Chief Medical Officer, Saint Vincent’s Healthcare, Ascension Health), Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), Lynn Razzano RN, MSN, ONC-C (Clinical Nurse Consultant, PPAHS)

The lawsuit against Yorkville Endoscopy, where Joan Rivers stopped breathing and tragically died, has been settled. In the statement by her daughter, Melissa Rivers said that she is now “able to put the legal aspects of my mother’s death behind me and ensure that those culpable for her death have accepted responsibility for their actions quickly and without equivocation.”

To read the complete article in Outpatient Surgery, please click here.

In Amanda's Memory, Always Monitor
Opioid Safety, Respiratory Compromise

A Promise to Amanda Foundation Says “Capnography Saves Lives”: Physician-Patient Alliance for Health & Safety Remembers Amanda Abbiehl on 6th Death Anniversary

On the sixth death anniversary of 18-year old Amanda Abbiehl, July 17, 2016, the Physician-Patient Alliance for Health & Safety (PPAHS) noted that the motto of A Promise to Amanda Foundation – “Capnography Saves Lives” – is increasingly being realized.

“The passing of Amanda is a powerful reminder of the need for continuous electronic monitoring,” said Michael Wong, JD (Executive Director, PPAHS). “Since the inception of PPAHS, we have advocated for the safer use of opioids. Opioid Safety, for patients receiving opioids in hospital and healthcare facilities, is the management and minimization of the risks of respiratory compromise, adverse events, and death through continuous respiratory monitoring with pulse oximetry for oxygenation and with capnography for adequacy of ventilation.” Read More

Opioid Safety, Patient Safety, Respiratory Compromise

National Coalition for Alarm Management Safety and National Coalition to Promote Continuous Monitoring of Patients on Opioids Recognized for Contribution to Patient Safety

The Physician-Patient Alliance for Health & Safety (PPAHS) is pleased to announce that the American Society of Association Executives (ASAE) has bestowed a prestigious national gold award on the AAMI Foundation for its patient safety initiatives, specifically the contributions of its National Coalition for Alarm Management Safety and National Coalition to Promote Continuous Monitoring of Patients on Opioids.

PPAHS is a proud member of the National Coalition for Alarm Management Safety and the National Coalition to Promote Continuous Monitoring of Patients on Opioids. Read More

Opioid Safety, Respiratory Compromise

Overdose Risk Assessment in Chronic Opioid Therapy

By Peggie L. Powell, MSN, APRN, FNP-BC

Over 100 million people suffer from chronic pain in the United States, and for some of these people, chronic opioid therapy (COT) may be appropriate. Despite the limited availability of strong scientific evidence to support long-term opioid therapy for chronic noncancer pain, COT has increased substantially over the years along with an increase in drug related deaths.

Prescription opioid related deaths have quadrupled since 1999 in the United States and approximately 80% of deaths are due to unintentional overdose. The addictive nature of opioids makes them vulnerable to misuse and abuse. Persons whom take opioids for their intended purpose can risk significant adverse events if they do not take them as prescribed (e.g., taking more than prescribed and taking them in combination with other psychotropic medications and/or alcohol). Opioids can depress the central nervous system and result in serious, life-threatening consequences such as respiratory depression, sedation, coma, and potentially death. Read More

Patient Safety

Thousands of Eyes and Ears to Promote Patient Safety

By Jeff Segal, MD, JD (founder and CEO of eMerit)

I tackled this proposition at the recent conference “15th Annual Advanced Forum on Obstetric Malpractice Claims.” Speaking on the panel discussion with me were:

  • Bruce Patsner, MD (Vice Chair, Quality, INOVA)
  • Angela W. Russell (Partner, Wilson Elser Moskowitz Edelman & Dicker LLP)
  • Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety)

I noted that far too often patients and staff see near-misses (which should more accurately be called near-hits), and say nothing. These early warning signals receive no action. Why? Because no one transmits this information to anyone with authority to take action. These are missed opportunities. Read More

Prince - source: https://en.wikipedia.org/wiki/Prince_(musician)
Opioid Safety, Respiratory Compromise

Prince’s Fentanyl Overdose Should Prompt Us to Ask “Where Does Opioid Use Begin?”

One of the great musicians of our age is dead – fentanyl is to blame – Prince’s could have been from preventable … these are the sentiments that are enough for public outrage to point to fentanyl as the ultimate killer and call for tighter, more stringent control of opioids and their prescription.

Forgotten in this discussion which brings together Prince, fentanyl, and death and the subsequent knee-jerk reaction to restrict the use of opioids is the vital role that opioids play in the management of pain, such as during surgery or to relieve chronic pain. The use of opioids often begins in the doctor’s office or as a result of a medical procedure. Read More

Patient Safety

What Can Be Done about Medical Errors?

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

Editor’s note: This article was first published in TheDoctorWeighsIn. It discusses recent research showing that medical errors constitute the third leading cause of death in the US and the need to develop high reliability in hospitals.

A new study published in the British Medical Journal by Martin A Makary, MD, and Michael Daniel, MD (both from the Department of Surgery at Johns Hopkins University School of Medicine) estimates that more than 250,000 deaths due to medical error occur in the United States alone. Read More

Top Median Malpractice Payments
Opioid Safety, Respiratory Compromise

3 Lessons for Preventing Death and Brain Damage in Newborns and Their Mothers

Can death and brain damage in newborns and their delivering mothers be prevented?

This is the question Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety) asked at the recent conference 15th Annual Advanced Forum on Obstetric Malpractice Claims.Speaking on the panel discussion with Mr. Wong were: Read More

Opioid Safety, Patient Safety, Respiratory Compromise

Drawn Curtains, Muted Alarms, And Diverted Attention Lead To Tragedy In The Postanesthesia Care Unit

By Institute for Safe Medication Practices (ISMP)

Editor’s Note: This article first appeared on the ISMP website. It discusses the role that inadequate monitoring and muted alarms played in the recent tragic recent death of a 17-year old following a tonsillectomy. PPAHS has previously discussed deaths of pediatric patients following dental or oral procedures. We welcome your thoughts and comments on this issue.

Problem: Last April, a 17-year-old girl died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentaNYL in the postanesthesia care unit (PACU). The case made headline news again recently when a civil lawsuit filed by the teen’s parents was resolved. While it is too late to reverse the tragic outcome of this case, we call upon all hospitals and outpatient surgery centers to learn from the event and take action to prevent a similar tragedy in your facility. Read More