Opioid Safety, Respiratory Compromise

Today’s Must-Have: Capnography Monitoring During Conscious Sedation Clinical Education Podcast with Drs. Matt Kurrek and Richard Merchant

Today, the Physician-Patient Alliance for Health Safety released a clinical education podcast with Matt Kurrek, MD, FRCPC (Professor, Department of Anesthesia, University of Toronto) and Richard Merchant, MD, FRCPC (Clinical Professor, University of British Columbia, Department of Anesthesia, Pharmacology & Therapeutics).

Drs. Kurrek and Merchant coauthored an editorial, “Yesterday’s Luxury, Today’s Necessity” after the Canadian Anesthesiologists’ Society [CSA] published its revised 2012 guidelines to the practice of anesthesia. The CSA guidelines recommend capnography monitoring during conscious sedation. In the podcast, Drs. Kurrek and Merchant discuss why capnography monitoring may have been considered yesterday’s luxury, but is now a necessity during conscious sedation.

Read More

Opioid Safety, Respiratory Compromise

Capnography The Ventilation Vital Sign

Editor’s Note: This research was presented as a poster at the 2017 ANCC National Magnet Conference.

By Eric Griffin MSN, RN, CEN (Magnet Program Director, Baystate Medical Center) and Laura Bolella MSN, RN (Assistant Nurse Manager, Baystate Medical Center)

For over a hundred years nurses have monitored the same vital signs. Unfortunately these vital signs can be slow to change, inaccurate, and misleading. Although there have been modern advances in physiological monitoring devices, their acceptance has been limited. Pulse oximetry developed in the early 1970’s is extremely useful in measuring oxygenation, although it has limitations related to the following factors: poor signal strength, fingernail polish, anemia, patient motion, calloused skin, hypoperfusion, time lag, and vasoconstriction.

Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Capnography Monitoring of Five-Year Old Amber Athwal May Have Prevented Her Brain Damage

The recent case of five-year old Amber Athwal is a reminder yet again of the dangers of dental sedation without the availability of adequate personnel and patient monitoring. Unfortunately, what happened to Amber is not an isolated event, as other pediatric deaths have recently occurred, tragically with 6 year-old Caleb Sears, as well as 9-year old Solomon Womack, 17-Year Old Mariah Edwards, and 17-year-old girl, Sydney Gallegher. Read More

Alarm Fatigue, Hospital Acquired Conditions

Advances in Alarm Management and Surveillance Monitoring

Written by James Welch, CEO Arc Biomedical Consultants (jwelch@arcbiomed.com)

james-welch

Mr. Welch is a Clinical Engineer with 17 yrs experience in hospitals and over 24 yrs as an executive in the medical device industry. His focus has been on applying technologies to improve patient safety through continuous surveillance monitoring. Mr. Welch has ten patents and articles in the field of wireless physiologic monitoring, surveillance systems and alarm management. He regularly contributes to the AAMI Foundation on alarm safety and is a voting member on a number of International Standards committees.

Early detection of physiologic deterioration is essential in improving patient safety in acute care hospital settings.  Patients in non-ICU settings who are recovering from surgery or special procedures are especially vulnerable because of private or semi-private room settings prevents direct observation and nurse to patient ratios are often 1:6. Experts in Rapid Response Systems (RRS) have arrived at a consensus that strengthening early detection through continuous monitoring is essential in improving the effectiveness of RRS but only if such systems do not impose a burden on the clinical staff. The high incidence of nuisance alarms and cost are two of the major barriers preventing broader adoption of continuous monitoring on the general care floor. Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Remembering Amanda: 7 Years After An Opioid-Related Death

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. Read More

Opioid Safety, Patient Stories, Practices & Tips, Respiratory Compromise

The Preventable Death of Paul Buisson: 3 Lessons on Preventing Opioid Death

The following is an excerpt of an article first published on The Doctor Weighs In on June 28, 2017. To read the full article, please click here.

In 2005, Paul Buisson, a celebrated Quebec animator and cameraman died as a result of opioid-related respiratory depression. What lessons can we learn more than a decade later? Read More

Opioid Safety, Position Statement, Respiratory Compromise

Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring

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. Read More

Hospital Acquired Conditions, Opioid Safety, Respiratory Compromise

Anesthesiology Standards Shouldn’t be Different in Hospital and Outpatient Settings

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?

The reality is that the definition of best practice and standard of care differs between acute care hospital settings and outpatient surgery centers. And, even then, the standard of care being applied by the ambulatory surgical center, anesthesiologist and the gastroenterologist may not be the same. Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Tyler’s Story: A Deadly PCA Medical Error

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. Read More

Hospital Acquired Conditions, Opioid Safety, Patient Safety, Respiratory Compromise

Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video

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 opioid epidemic was one of the most heavily-covered, and hotly-debated, topic in patient safety covered in 2016. This dialogue has been mostly centered around the effects of ‘street’ use and abuse of prescription painkillers. In contrast, the PPAHS podcast series aims to highlight the preventable harm of opioid-induced respiratory depression during hospital procedures. Read More