Opioid Safety, Respiratory Compromise

5 Facts that Makes Patients with Obstructive Sleep Apnea More At-Risk for Death Research shows respiratory compromise may occur with obstructive sleep apnea patients receiving opioids

Researchers have found that respiratory compromise may occur with obstructive sleep apnea (OSA) patients receiving opioids.

Research conducted by Yamini Subramani, MD et al, “Death or near-death in patients with obstructive sleep apnoea: a compendium of case reports of critical complications” found 5 reasons why the risk of death is higher in patients with obstructive sleep apnea (OSA).

After removing for duplicates, the researchers analyzed more than 1,000 patient cases.

# 1 Fact – Patients can have obstructive sleep apnea and not know it

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Opioid Safety, Patient Safety, Respiratory Compromise

Drawn Curtains, Muted Alarms, And Diverted Attention Lead To Tragedy In The Postanesthesia Care Unit Inadequate monitoring and muted alarms may lead to patient deaths

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

Opioid Safety, Respiratory Compromise

Are Hospitals Giving Away Money?

At a recent presentation in Washington DC, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety) asked, “Are hospitals giving away money?”

An analysis of more than 3,300 closed claims of the American Society of Anesthesiologists by Julia I. Metzner, MD, “Risks of Anesthesia at Remote Locations” shows that:

  • Almost 1 in 10 events were preventable with monitoring (8.6%)
  • About 1 in 4 events were due to substandard care (37.4%)

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Opioid Safety, Respiratory Compromise

6-Month Return on Investment of Continuous Electronic Monitoring: An Interview with Eyal Zimlichman, MD

Eyal Zimlichman, M.D., MSc., holds dual appointments as Deputy Director General and Chief Quality Officer at Sheba Medical Center in Israel and at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and Harvard Medical School.

In an in-depth discussion with the Physician-Patient Alliance for Health & Safety (PPAHS), Dr. Zimlichman discusses his research, experience, and thoughts on continuous electronic monitoring. He says that his research of a continuous electronic monitoring system has shown a 6-month break-even point for acquisition and implementation, and thereafter cost savings. To listen to the interview with Dr. Zimlichman on YouTube, please click here.

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Opioid Safety, Respiratory Compromise

A How-To Guide for Reducing Adverse Drug Events Related to Opioids (RADEO)

By Sean Power

Respiratory compromise is the primary antecedent to ‘code blue’, the leading trigger of rapid response calls, and the number one cause of ICU admissions. Respiratory compromise is one of three indicators accounting for 66 percent of all preventable patient safety issues and causes higher mortality rates, longer hospital and ICU stays, and millions of healthcare dollars every year.

Respiratory compromise consists of respiratory insufficiency, distress, arrest, and failure. Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

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Patient Safety

Patient-Controlled Analgesia Use in Labor – Weekly Must Reads in Patient Safety (Dec 4, 2015)

Recent research has found that 70 percent of women in labor using patient-controlled analgesia (PCA) experienced oxygen desaturation. Oxygen desaturation is defined as a “decrease in oxygen concentration in the blood resulting from any condition that affects the exchange of carbon dioxide and oxygen”.

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