Opioid Safety, Patient Stories, Respiratory Compromise

Nursing Spot Checks for Patient Safety: A Nurse’s Perspective

(This article first published in Advance for Nurses, which covers the issues that matter most to nurses practicing in all areas of the profession. As that publication winds down, we have archived some articles here.)

By Malinda Loflin, RN, BSN. Malinda is a certified case manager at a hospital in Oklahoma City. During her 22 years as a registered nurse, her clinical experience has been in many specialty areas including the operating room, post-anesthesia care unit, and the emergency department. In 2006, her father tragically died of opioid-induced respiratory depression after a routine surgery. She shared her experience and the impact that it has had on her and her family at the 2011 Anesthesia Patient Safety Conference.

Nursing spot checks on postoperative patients receiving opioids are not enough to ensure the safety of patients. I say this as both a registered nurse who works at a large medical center and as a daughter who has had the misfortune of seeing her own father die between nurses’ spot checks. Read More

Opioid Safety, Respiratory Compromise

Update on CMS Proposed Quality Measure on PCA Patient Safety

We would like to thank all of those who submitted comments on the proposed quality measure being considered by CMS regarding the monitoring of patients using patient-controlled analgesia (PCA) pumps.

In the report submitted by the National Quality Forum to the United States Department of Health and Human Services, the measure was not endorsed and it was decided that the measure “requires modification or further development”. More particularly, the report provides: Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Does CMS Proposed Measure for PCA Safety Go Far Enough?

by Michael Wong

(This article is reprinted with the permission of Patient Safety & Quality Healthcare (PSQH).)

This is the question that I have been asking myself ever since Centers for Medicare & Medicaid Services (CMS) recently announced proposed quality measures it is considering for adoption through rule making for the Medicare program. Read More

Alarm Fatigue, Opioid Safety, Respiratory Compromise

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.” Read More