Physician-Patient Alliance for Health & Safety Turns 4 Years Old

The Physician-Patient Alliance for Health & Safety (PPAHS) today celebrates its fourth anniversary.

PPAHS posted its first blog on July 27, 2011, “Is it possible to survive 96-minutes without a heart beat?”.

This post featured what happened to Howard Snitzer, who suffered a heart attack outside of a grocery store in Goodhue, Minnesota. Two volunteer paramedics responded and began a 96-minute CPR marathon involving 20 others, who took turns pumping his chest.

(To see the Mayo Clinic video on Howard Snitzer, please go to https://www.youtube.com/watch?v=IsPq3oQZGNs&feature=youtu.be)

Generally, if a victim’s pulse has not returned after 45 minutes of CPR, resuscitation is discontinued. However, fortunately for Howard, the paramedics were using capnography, a “monitoring device that measures the concentration of carbon dioxide in exhaled air and displays a numerical readout and waveform tracing.”

In writing about his experience, Mr. Snitzer says, “I hope that more rescue squads will acquire the Capnograph in the future. I have already heard stories about that happening as a result of people reading my story. If even one other person is helped by this then all the efforts that went into my rescue were worth it. I hope this helps thousands.”

“PPAHS was started with a simple goal – save one life from unnecessary death,” said Michael W. Wong, JD (Founder and Executive Director, PPAHS). “Since that time, PPAHS has together with leading health experts developed the PCA Safety Checklist for patients receiving opioids through patient-controlled analgesia, the OB VTE Recommendations to prevent blood clots in pregnant and delivering mothers, and the Stroke VTE Safety Recommendations to reduce the incidence of blood clots in stroke patients.”

PPAHS is engaged in the following key initiatives for improving patient safety and health outcomes:

• Alarm Fatigue
• Blood Clots(Venous Thromboembolism – VTE)
• Patient Monitoring

Podcast on Continuous Electronic Monitoring

In this podcast AAMI Foundation’s Healthcare Technology Safety Institute, Frank Overdyk, MD, professor of anesthesiology at Hofstra North Shore-LIJ School of Medicine and executive director for research at North American Partners in Anesthesia, and Tim Vanderveen, vice president of CareFusion’s Center for Safety and Clinical Excellence, make the case for continuous electronic monitoring and address the challenges stakeholders face in trying to bring about this change.

Dr. Overdyk is an advisor to the Physician-Patient Alliance for Health & Safety and, with Mr. Vanderveen, is a co-chair of the National Coalition to Promote Continuous Monitoring of Patients on Opioids.

To listen to the podcast, please see “Episode 7” by clicking here.

Outpatient Centers vs. Hospitals: Lessons Learned from the Death of Joan Rivers

The headline of a recent Washington Post article reads “Joan Rivers’s death spurs new look at outpatient centers”.

Although ABC News reports that the outpatient center that treated Joan Rivers is losing both Medicare certification and accreditation from the American Association for Accreditation of Ambulatory Surgery Facilities (AAASF), Kenneth P. Rothfield, MD, MBA, CPE, CPPS (System Vice President, Chief Medical Officer, Saint Vincent’s Healthcare, Ascension Health) points out that the question is not whether outpatient centers are better or worse than hospitals, but whether the facility is properly equipped and personnel adequately trained:

“I don’t think it’s the venue that’s the most important thing,” said Rothfield, a member of the board [of advisors] of the Physician-Patient Alliance for Health & Safety, a nonprofit group. “ASCs [ambulatory surgery centers] traditionally have done simpler procedures in healthy patients,” while hospitals have routinely dealt with a broader — and sicker — mix of people. Hospitals, he said, are more likely to be fully equipped and to have staff members with greater experience handling emergencies. “Unless you have drilled for it, and trained for it, it can be hard to pull off.”

In addition, the medical standards of care upheld by healthcare facilities may differ. Although hospitals typically seek accreditation from The Joint Commission, ambulatory centers can receive accreditation from a variety of organizations. For example, the AAASF accredits ambulatory surgery facilities like the one where Joan Rivers underwent her medical procedure.

How might these standards specifically differ?

In the article “Medical standards of care and the Joan Rivers death,” differing standards of monitoring patients receiving opioids are discussed:

What is instructive in terms of gained knowledge in the Joan Rivers’ death are the differing patient safety measures in place by the application of standards when a sedative is delivered to the patient.

The AAAASF standard would have monitored for oxygenation by pulse oximeter, which measures the amount of oxygen in blood. Measuring oxygenation provides a very late indicator of hypoventilation, or ineffective breathing. In other words, there would have been a delay in the detection of low blood oxygenation by pulse oximeter.

The ASA [American Society of Anesthesiologists] standards provide an extra level of patient safety by requiring that the adequacy of ventilation be monitored in addition to oxygenation. The ASA standards therefore call for the “continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide”.

Even in hospitals, however, multiple standards of care may exist. Although anesthesiologists, the recognized experts in providing safe sedation, are required to monitor adequacy of breathing by measuring exhaled carbon dioxide, non-anesthesiologists such as gastroenterologists, surgeons, and radiologists are not required to provide this extra measure of safety. For example, American Society for Gastrointestinal Endoscopy “Guidelines for safety in the gastrointestinal endoscopy unit” does not require monitoring for adequacy of ventilation by Capnography, as required by the ASA.

So, how can patients decide on which healthcare facility to undergo a surgical procedure?

The Physician-Patient Alliance for Health & Safety offers four simple points to keep in mind:

1. Even “minor” procedures can have major risks and “hidden harm”

The ASA reminds us that although “anesthesia is safer than ever before, every person scheduled for a procedure or surgery must have a serious conversation with their physician anesthesiologist about their anesthesia care delivery plan ahead of time … Even ‘minor procedures’ are not risk-free.”

2. Ask questions to fully understand the medical procedure you are to undergo

Physicians must communicate and patients need to fully understand the full nature of the medical procedure. It is often helpful to have a family member, friend or significant other with you to check if you asked all your questions and another set of “ears” to listen to what is being told or explained to you.

U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) believe “clinicians and patients [need] to engage in effective two-way communication to ensure safer care and better health outcomes.”

This type of patient engagement and education should be told to the patient, and then to ensure an adequate level of understanding the clinician should ask for verbal or written feedback from the patient..This validates the patient’s understanding and is termed ”readback feedback”.

AHRQ encourages patients to ask their medical providers questions, as illustrated in this humorous video which shows how patients ask many questions everywhere (such as in a restaurant) but not in the doctor’s office (please click on the image to view the video):

AHRQ Restaurant Ad

3. Make sure you are monitored electronically, with both pulse oximetry and capnography, if you are to receive sedation, opioids or anesthesia

Even “routine” procedures may entail the use of a sedative, opioids, or anesthesia, additionally there maybe use of a combination of more than one of these medications. The endoscopic procedure performed on Ms. Rivers, which would have likely involved insertion of a large scope into her mouth, is a simple and common procedure, but, as noted by Dr. Karen Siebert, “uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.” The type of sedation given can be Monitored Anesthesia Care (MAC) or I.V. Conscious sedation.

The Anesthesia Patient Safety Foundation (APSF) believes that clinically significant drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.

Continually evaluating and monitoring respiratory and circulatory status prior to, during, and following the procedure is essential. As a recent video released by the APSF demonstrates continuous electronic monitoring of oxygenation (the adequacy of oxygen in the blood) with pulse oximetry and ventilation (adequacy of breathing) with capnography, These combined with traditional in-depth nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment and distress.

Virtually all proceduralists use pulse oximetry to measure blood oxygen levels as a standard of practice. Assessing ventilation is another issue. The ability to tell by simple observation if a patient is breathing adequately or not during a procedure can be tricky. Surprisingly, standards for capnography monitoring are not the same for all medical specialists.

Anesthesiologists are required by the ASA to measure the adequacy of ventilation using capnography (a device which measures exhaled carbon dioxide) to provide breath-by-breath monitoring. Other specialists, such as gastroenterologists and dentists, are not required to use this technology. Without capnography, several critical minutes can elapse after a patient stops breathing before medical professionals are alerted to the situation. Unfortunately, by this time, a serious problem or even a cardiac arrest may occur.

4. Equipment and resources at an outpatient clinic may be different than at a hospital

If your procedure is scheduled at an outpatient clinic be sure to ask about available emergency equipment at the clinic. Just because your procedure is scheduled in an outpatient type of clinic, do not take this lightly and ask about code cart availability, emergency drugs to manage your condition and any adverse events, and lastly trained clinicians available and knowledgeable about handling potential life threatening emergencies.

As Dr. Rothfield cautions, the venue does not necessarily dictate better patient safety and health outcomes. Ensuring that the facility is properly equipped, its personnel adequately trained and whether its patients receiving opioids are continuously monitored – these are some key questions.

What Did Joan Rivers Die From?

Reports WomensHealth:

As more details emerge about Joan Rivers’ death, one thing is clear: It could have been prevented. When it comes to elective surgery, even famous people – who have access to the best – aren’t immune to complications …

One lesson we can learn from this tragedy is to think – more than twice – before going through any non-essential surgery, says Dr. Marc Leavey, primary care specialist at Mercy Medical Center. In his career, he has seen people want unnecessary surgery, cosmetic or otherwise. After fighting to have it, they end up with untoward complications from disability to death. “Surgery is surgery, whether ‘major’ or ‘minor,’ and should not be entered into lightly,” he says.

To read the full article and WomensHealth’s citation of the Physician-Patient Alliance for Health & Safety’s four ways in which patients can learn from Rivers’ experience, please click here.

Healthcare Leaders to Meet on Respiratory Compromise To Improve Patient Safety and Save Lives

Respiratory compromise is the second-most frequently occurring preventable patient safety issue and causes higher mortality rates, longer hospital and ICU stays, and millions of healthcare dollars every single year. It is the third most rapidly increasing hospital inpatient cost in the United States. Respiratory compromise consists of respiratory insufficiency, distress, arrest, and failure.

In a special roundtable discussion to be hosted by the National Association for Medical Direction of Respiratory Care (NAMDRC), healthcare leaders from pulmonary medicine and related fields will review and discuss how to reduce the risk of respiratory compromise.

“Patients admitted to acute care hospitals for a variety of reasons are often at risk for worsening respiratory function that can progress to respiratory failure and poor outcomes,” explained Dennis E. Doherty, MD (President, NAMDRC, Professor, University of Kentucky College of Medicine). “By bringing together key healthcare leaders, we will discuss whether we are missing opportunities to intervene in order to prevent respiratory failure.”

The Physician-Patient Alliance for Health & Safety recently established the Respiratory Compromise Institute (RCI) to leverage industry thought leaders and clinical teams to develop the tools and encourage the research needed to make the changes necessary to save lives from respiratory compromise.

Describing RCI as a broad-based coalition of organizations, companies, and individuals, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety) said, “The goal of RCI is to reduce —and eventually eliminating—preventable adverse events and deaths due to respiratory depression.”

Could Intraoperative Handoff Checklists Prevent Medical Errors?

by Sean Power
February 17, 2015

The Joint Commission estimates that 80 percent of medical errors involve miscommunication between caregivers during the handoff between medical providers.

New research published in Anesthesia & Analgesia suggests that an electronic checklist may help, especially during intraoperative transfers of care.

Handoffs can be high-risk error-prone patient care episodes. The risk is rooted in several possible causes: inaccurate information; lack of consistency, organization, and standardization in how information is communicated; distractions and information overload, to name a few.

A team of researchers at Massachusetts General Hospital and Harvard Medical School led by Aalok V. Agarwala, MD, MBA, compared relay and retention of critical patient information between the outgoing and incoming anesthesiologist before and after introducing a checklist.

The goal of the checklist developed by the researchers was to improve the quality of the handoff process along with care.

For handoffs in which the checklist was used, the authors observed statistically significant improvements in the relay of two main categories of information: intraoperative medication and fluid balance.

This improvement was associated with a larger percentage of anesthesiologists being able to recall patient information after the handoff took place.

Key Information Relayed at Handoff

The electronic handoff checklist consisted of fields containing important patient data:

• Demographics including age, weight, and body mass index
• Past medical history and medications
• Airway
• Access
• Fluids
• Perioperative medications
• Antibiotics
• Intraoperative concerns
• Postoperative plan
• Introduction of incoming anesthesia provider

Where possible, fields were pre-populated with data collected from an anesthesia information management system. Checkboxes were used so that the outgoing anesthesiologist could verify the accuracy of information at handoff.

The team observed 30 handoffs without the checklist and 39 with it. They looked for changes in how frequently communication was relayed and how effectively this knowledge was retained.

Improvements in Information Relay and Retention

The researchers observed improvements in relay in several areas:

• Administration of vasopressors and antiemetics
• Estimated blood loss and urine output
• Communication about potential areas of concern
• Postoperative planning, and
• Introduction of the relieving anesthesiologist to the operating team.

The checklist improved knowledge retention, as well. Specifically, the relieving anesthesiologist more frequently knew the antibiotic and muscle relaxant used, as well as the amount of fluid administered.

Clinicians who used the checklist in at least 67 percent of their handoffs reported higher satisfaction with quality of communication at handoff.

Perhaps most impressive (or alarming, depending on how you look at it): the checklist improved how frequently the incoming anesthesiologist was introduced to the rest of the operative team, from 3 percent of the time to 51 percent of the time.

Post-Handoff Assessment: Satisfaction with Handoff

As part of the research, the authors assessed the relieving anesthesiologist’s satisfaction with the information conveyed and retention of information transferred.

Satisfaction levels trended toward improvement in perceived quality of communication.

This trend did not reach statistical significance, although it held true across all provider groups (clinicians, faculty anesthesiologists, trainees, and CRNAs).

There was, however, a significant reduction in the perception that the handoff was rushed when the checklist was used, even though the duration of handoffs performed with and without the checklist was not significantly different.

Voluntary Adoption

In January 2013 (three months after the checklist’s introduction in October 2012), the checklist was used in 60 percent of intraoperative handoffs.

By June, that figure had reached 74 percent.

Could electronic intraoperative handoff checklists improve patient safety?

These findings point to yes—and the increase in voluntary uptake seems to suggest that operating teams might think so, too.

What do you think? Leave your answer and thoughts below.

Weekly Must Reads in Patient Safety (Feb 13, 2015)

We hope there are no superstitious people reading on this Friday the 13th.

Let’s get to it. Must Reads from the past week.

New Stroke VTE Safety Recommendations Prevent Blood Clots In Stroke Patients

Earlier this week, PPAHS announced the release of safety recommendations targeting the prevention of venous thromboembolism (VTE) in stroke patients.

Stroke is a leading cause of death and disability in the U.S., with 800,000 cases occurring each year.

Download the Stroke VTE Safety Recommendations here.

Four Reasons to Expand Capnography

Advance Healthcare Network for Respiratory Care & Sleep Medicine published an article outlining why health systems should expand the use of capnography.

1. Enhancing patient safety
2. Newer guidelines and checklists to monitor patients
3. Improved outcomes
4. Improved consistency of care.

Citing experts like Dr. Bhavini Kodali, Dr. Frank Overdyk (who sits on the PPAHS board of advisors)—and referencing the PPAHS PCA Safety Checklist—the article is a good summary of why capnography use should be expanded outside the OR.

Health Illiteracy a Root Cause of Medical Error

In 2004, The Institute of Medicine (IOM) released a report, saying that that 90 million people in America have difficulty understanding and using health information.

On a personal blog, Thomas Sharon, RN, MPH, recently shared his perspective on patients who lacked basic health literacy after encountering thousands of patients in the home environment over two decades. It is always good to get perspectives from the field, so we thought we would highlight this blog article.

Both the IOM report brief and Mr. Sharon’s article may be worth reading.

Patient Satisfaction Scores Not Affected by Amount of Opioids Given in Emergency Room

Pain Medicine News reports that researchers at two New England hospitals performed a retrospective analysis of medical records and completed surveys of nearly 5,000 patients seen in the ER department.

The researchers asked whether the amount of opioids administered in the ER were associated with Press Ganey scores, a common tool to measure patient satisfaction, according to the authors. The answer, they found: no.

According to Chris Pasero, pain management educator and clinical consultant:

“What’s happening nation-wide is a focus on opioid-only treatment plans. This is problematic.”

The new research may strengthen the case for multi-modal pain management programs.

Can Turning Down Alarms Improve Patient Safety?

A study from one of the intensive care units at Abbott Northwestern Hospital looked at whether changing default settings of pulse-rate alarms could improve patient safety.

By changing the thresholds, the study found that the number of pulse rate alarms dropped 76 percent within six months without any emergencies being missed.

Researchers at Dartmouth-Hitchcock Medical Center likewise observed benefits from revising default alarm settings.

Thanks, @AAMIFoundation and others, for tweeting about the Abbott story.

https://twitter.com/AAMIFoundation/status/564820613559513089

Vanderbilt University Medical Center Improves Health Outcomes and Financial Performance Through Continuous Monitoring of Low-acuity Patients

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

Vanderbilt University Medical Center (VUMC) is a highly respected comprehensive healthcare facility in the Mid-South region of the United States. Leaders like VUMC lead the way for safer patient care and improved health outcomes.

So, when Brian Rothman, MD (Associate Professor, Division of Multispecialty Adult Anesthesiology and Medical Director of Perioperative Informatics) recently spoke at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids about VUMC’s experience with continuous monitoring of low-acuity patients, I took the opportunity to interview him about this experience and what advice he would give to other healthcare facilities looking to similarly improve patient safety and outcomes.

Dr. Rothman told me that “Currently, monitoring of patients on the general care floor is continual (at regular intervals), not continuous. This means that a nurse assesses a particular patient on an intermittent basis. To me, checking on a patient every 4 or 6 hours is like checking to see if the fridge light is on.”

http://www.niemanlab.org/images/smart-refrigerator.jpg

To read a full copy of the article, please click here.

Two Practices to Adopt After Pediatric Opioid Trial Halted

By Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

With more than 500,000 pediatric tonsillectomies performed each year in the United States, removal of tonsils is one of the most common surgeries performed on children. According to the American Academy of Otolaryngology Head and Neck Surgery, tonsillectomy is performed 20 percent for infection and 80 percent for obstructive sleep apnea.

(for more on opioids and patent safety, please see click on the picture)

Children undergoing tonsillectomy with or without adenoidectomy are routinely given morphine to manage their pain following surgery. This standard practice of using morphine is being called into question by a recent study conducted by the Motherisk Program at The Hospital for Sick Children (SickKids) and by McMaster University and McMaster Children’s Hospital.

The study results were published in the January 2015 issue of Pediatrics, after the study’s Drug Safety Monitoring Board halted the trial following an interim analysis which strongly demonstrated a high degree of risk of respiratory compromise associated with the use of morphine. One child even suffered a life-threatening adverse drug reaction including oxygen desaturation after being treated with morphine.

What lessons can be learned from this trial?

1. Opioids Should be Prescribed Cautiously, not Routinely

Study co-author Doron Sommer, MD (Clinical Professor of Surgery, McMaster’s Michael G. DeGroote School of Medicine; surgeon, McMaster Children’s Hospital) explained:

These results should prompt clinicians to re-evaluate their post-tonsillectomy pain treatment regimen. Due to the unpredictable respiratory side-effects of morphine, its use as a first-line treatment with current dosage ranges should be discontinued for outpatient tonsillectomy.

The study found that using Ibuprofen in combination with acetaminophen provides safe and effective analgesia in children. As fellow researcher Gideon Koren, MD, FRCPC (Director, Motherisk Program; Senior Scientist, SickKids) said,

The good news is that we now have evidence that indicates ibuprofen is safe for these kids, and is just as effective in controlling their pain, so there’s a good alternative available for clinicians to prescribe.

2. If Opioids are Prescribed, Patients Should be Monitored

The Joint Commission cautions that an opioid analgesic like morphine, although usually safe, may be associated with adverse effects, the most serious being respiratory depression preceded by sedation.

EurekAlert! reports that at “both SickKids and McMaster Children’s Hospital, the use of morphine for post-operative pain from pediatric tonsillectomy is reserved for exceptional cases where it is deemed necessary and safe with appropriate monitoring.”

What should the “appropriate monitoring” be?

The National Coalition to Promote Continuous Monitoring of Patients on Opioids recently had its inaugural meeting. The goal of the Coalition is “to establish the business case, demonstrating strong financial justification and improved patient outcomes, and to educate and encourage hospitals to adopt continuous monitoring for all patients on opioids.”

Co-conveners of the Coalition’s inaugural meeting included The Joint Commission, The Anesthesia Patient Safety Foundation, the Institute for Safe Medication Practices, the National Patient Safety Foundation, and the VA National Center for Patient Safety.

The Physician-Patient Alliance for Health & Safety, also a co-convener, recently issued this statement in support of the objectives of the National Coalition to Promote Continuous Monitoring of Patients on Opioids:

To improve patient safety and save patients’ lives, we recommend adopting continuous respiratory monitoring of all patients receiving opioids with pulse oximetry for oxygenation and with capnography for adequacy of ventilation to improve timely recognition of respiratory depression, decompensation or clinical deterioration.

Concludes Gina Pugliese, RN, MS (Vice president, Premier Safety Institute):

We need to promote the safe and responsible use of opioids. One place to start is with common procedures like tonsillectomies. The Motherisk Program shows us that opioids can be safely and effectively be replaced with non-opioid alternatives. That said, if opioids must be used, to prevent respiratory depression and improve safety, patients receiving opioids should be continuously electronically monitored.

 

Weekly Must Reads in Patient Safety (Jan 23, 2015)

Alarms! Alarms! Alarms! … and a family seeks answers to death at a VA hospital.

But, before we get to the serious news … a little humor …

(Source: The Happy Hospitalist)

The Alarm vs. Alert Conundrum

Sue Montgomery, RN, BSN, CHPN reminds us about the difference between “alarms” and “alerts”:

The terms “alarm” and “alert” are often used interchangeably, but they’re not the same thing. Alarms usually indicate a potentially life-threatening situation requiring an immediate response and are regulated by the FDA as part of the agency’s oversight of medical devices. By contrast, alerts are usually associated with non-medical devices and don’t indicate an immediate crisis. Some examples include nurse call systems and message notifications.

Alerts might be less critical than alarms, which is why they’re not regulated in the same way, but they both add to the general cacophony nurses face every day. Several studies have found that it’s difficult for most people to differentiate more than six different alarm sounds, but the American Association of Critical Care Nurses says the average ICU nurse must cope with more than three dozen sounds. It’s no wonder that alarm overload or alarm fatigue is becoming epidemic.

Alarm Fatigue and Telehealth

According to ECRI, alarm fatigue-reducing technologies and telehealth are among the top 10 technology tools hospital executives should watch for in 2015.

ECRI Institute’s 2015 Top 10 Hospital C-Suite Watch List is available as a free public service. It seeks to provide “answers [to] key questions on new and emerging health technologies that potentially provide new ways to treat patients, improve care, and reduce costs.”

Alarm Fatigue, Telehealth Top ECRI's Hospital C-Suite List for 2015 http://t.co/OJiipN9cqq

— Geeta Nayyar, MD MBA (@drgnayyar) January 16, 2015

Thanks to @gnayyar, @IVCiLLC, and @iHealthBlog for tweeting about this!

Man’s Family Seeks Answers After His Death at a VA Hospital

As reported by the Post Register in Idaho Falls, Idaho (note: access to the full article is only for Post Register subscribers), Richard Palmer was the victim of over-sedation after undergoing routine surgery:

Richard Palmer, awoke June 11 feeling well after undergoing routine surgery. He called his daughter at 3:30 p.m. to check in with her following the procedure.

After the operation, a catheter was placed in Palmer’s femoral nerve to administer a local anesthetic — bupivacaine — to manage his pain.

The VA later learned the pump, which regulates how fast the medicine is released, was not assembled properly, leading to the free-flow of the anesthetic for 11 minutes.

According to the medical examiner’s report, Palmer reported feeling anxious and having a tingling sensation in his feet. Then he had a seizure.

At 5:15 p.m., a blood test showed Palmer had 14 times more bupivacaine in his system than he was supposed to. At 7:29 p.m., he was pronounced dead.

Editor’s note: Use of the PCA Safety Checklist may have averted this tragedy. One of the steps to be followed before initiating, refilling, or programming change is to have two healthcare providers independently verify:

• patient’s identification
• all patient allergies appear prominently on medication administration record (MAR)
• drug selection and concentration confirmed as that which was prescribed
• any necessary dose adjustments completed
• PCA pump settings
• line attachment to patient and tubing insertion into pump

Sounds simple – but simple could have saved a life.