Opioid Deaths Are (Still) Preventable: The Physician-Patient Alliance for Health & Safety Remembers Leah

Following an elective surgery, Leah was given fentanyl, a powerful opioid, to manage her pain.  She was not placed under continuous electronic monitoring while recovering, a technology that would have provided hospital staff with an early warning of respiratory distress.  Instead, Leah's mother, Lenore Alexander, woke at the side of her hospital bed to find her daughter dead.

"Four years ago we published an article with Lenore asking if continuous monitoring would have saved her girl," says Michael Wong, JD, Executive Director of PPAHS, "the answer was 'yes' then, and remains 'yes' to this day."

More than a decade of case studies has strengthened, rather than eroded, this position.  The PPAHS has featured countless articles and studies showing the successful use of continuous capnography monitoring in reducing opioid-related adverse events.  A landmark example is St. Joseph/Candler Hospitals in Savannah, GA; after implementing continuous electronic monitoring with capnography, St. Joseph/Candler has reduced adverse events to zero for now more than 12 years. 

Unfortunately, despite the evidence, opioid harm remains a top patient safety concern.  Opioid-related adverse events have, once again, kept a place on the ECRI Institute's Top 10 Health Technology Hazards for 2017. 

Moreover, opioid-related adverse events are preventable.  The PPAHS urges the medical community to learn from patient stories such as Leah's.  For clinicians, though the answer is multifaceted, it begins with the right processes and technology in place.  Here are six lessons from Pamela Parker, BSN, RN, CAPA:

1. All patients receiving opioids should be assessed for risk for over sedation and respiratory depression.
2. Clinicians must recognize the signs of respiratory compromise.
3. All patients receiving opioids should be continuously electronically monitored.
4. Do not rely upon pulse oximeters, monitor with capnography.
5. All patients should be monitored for an extended period in an un-stimulated environment prior to discharge.
6. Medical interventions should not be based upon human heroics, but should be based upon a process and process improvement.

Moreover, caregivers need the right tools to effectively engage with patients' families.  From Promise to Amanda, there are four essentials for safety:

1. Ensure patients/families are provided information on proper use of the PCA pump
2. Make sure patients/families understand why they must be monitored for safety reasons
3. Save yourself some trouble and educate patients and families about monitor readouts
4. Know why alarms sound and what to do when they sound

To learn more about Leah's story, please visit Leah's Legacy.  To read the full PPAHS article, please visit the PPAHS blog.

About Physician-Patient Alliance for Health & Safety

Physician-Patient Alliance for Health & Safety is a non-profit 501(c)(3) whose mission is to promote safer clinical practices and standards for patients through collaboration among healthcare experts, professionals, scientific researchers, and others, in order to improve healthcare delivery. For more information, please go to www.ppahs.org.

SOURCE Physician-Patient Alliance for Health & Safety (PPAHS)

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