Although use of patient-controlled analgesia (PCA) reduces the risk of oversedation, The Joint Commission Sentinel Event Alert on safe use of opioids in hospitals cautions:
“While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.”
According to the Food and Drug Administration (FDA) based on reports it received between 2005 and 2009, more than 56,000 adverse events and 700 patient deaths were linked to PCA. One out of 378 post-surgical patients are harmed or die from errors related to patient-controlled analgesia (PCA). To improve patient safety and health outcomes, the Anesthesia Patient Safety Foundation recently released recommendations calling for continuous electronic monitoring of oxygenation and ventilation. As Dr. Robert Stoelting (President, Anesthesia Patient Safety Foundation) explains:
“Clinically significant drug-induced respiratory depression (oxygenation and/or ventilation) in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.”
To address this issue of opioid-induced respiratory depression and the need for patient monitoring, PPAHS has engaged in numerous initiatives and activities, including:
- Patient Safety Checklist: Development of a safety checklist regarding use of patient-controlled analgesia.
- Speaking Engagements: Speaking to students at the invitation of University of Notre Dame, as well as presenting at and participated in conferences andwebinars, including:
- Crittenden Medical Conference 2012
- The Eleventh National Quality Colloquium
- Institute for Healthcare Improvement (IHI) 24th Annual National Forum on Quality Improvement in Health Care
- 60th Congress of the Association of Perioperative Registered Nurses (AORN)
- Premier Safety Institute webinar “Reducing ADEs and Harm Associated with Opioids: Safer Post-Operative Pain Management”
- California Hospital Engagement Network webinar “Preventing Opioid-Related Adverse Events: Patient Stories and Best Practices”
- Northern Regional Respiratory Care Conference
- Media Resource:PPAHS has received frequent media requests to comment, answer questions and or to submit articles by the many media outlets including:
- ABC News
- Becker’s Hospital Review
- CBS News
- Hospitalist News
- Internal Medicine News
- Los Angeles Times
- Outpatient Surgery
- Patient Safety & Quality Healthcare
- Project Health Radio
- UK Daily Mail
- USA Today
- Patient Access and Safety: Commented on and initiated discussion about patient access and safety issues, including:
- Best Practices: Promoted best practices illustrated by health care expert studies and examples, such as how:
- U.S. Department of Veterans Affairs believes it can prevent more than 60 percent of adverse events related to patient-controlled analgesia pumps.
- St. Joseph’s/Candler Hospitals in Savannah, Georgia, has not only had eight years of event-free use of PCA using “smart” PCA pumps with integrated capnography monitoring, but calculated that their decision made great financial sense: (a) $4 million — estimated potential expenses averted (not including potential litigation costs); and (b) $2.5 million — 5-year return on investment.
- Wesley Medical Center in Wichita, Kansas, for RT Magazine’s “Best of 2013 Respiratory Care Award” for bringing the percentage of moderate and severe patient-controlled analgesia adverse events progressing to code blue 13 percent to zero percent.