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.

Mayo Clinic Video Howard Snitzer

(To see the Mayo Clinic video on Howard Snitzer, please go to

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:

Capnography, Patient Monitoring, Patient Safety

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.

2If 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.


Capnography, Patient Monitoring

Opioid Therapy With Capnography: Postop pain management approach reduces rescue events by 90% at surgical hospital in Texas

By Jessica Hill, RN (VP of patient care services and chief nursing officer at Texas Health Southlake Hospital, Dallas)

The goal in the development of rapid response teams has been to prevent failure-to-rescue. This failure to recognize when a patient’s condition has deteriorated is a key contributor to in-hospital mortality.

The early detection of the onset of respiratory compromise is clearly a key in knowing when a patient’s condition has deteriorated. Consequently, it was the goal of early intervention that Texas Health Southlake Hospital sought to achieve.

Since we began monitoring our postoperative patients receiving opioids with capnography, our facility has experienced a 90% reduction in the number of rapid response activations.

To read the article in Advance for Nurses, please click here.


Alarm Fatigue, Capnography, Patient Safety, VTE, Weekly Must Reads in Patient Safety

Top 16 Patient Safety Must Reads of 2014

This year, the Physician-Patient Alliance for Health and Safety introduced a weekly round-up of must-read articles in patient safety. The hand-picked list has consistently seen high engagement from our dear readers.

With that in mind, we thought we would compile a list of the Top Patient Safety Must Reads of 2014.

Expansion of Use of Capnography for Patient Safety
August 22, 2014

For postsurgical patients receiving opioid pain medications, effective and continuous electronic respiratory monitoring is critical. As a result, an increasing number of health care institutions are expanding their use of capnography to ensure maximum patient safety and prevent adverse events that are predictable.

To read this RT Magazine article, please click here.

National Coalition for Alarm Management Safety
August 29, 2014

The National Coalition for Alarm Management is a group of thought-leaders sharing information with other pioneers in the “alarm-management space,” driving improvement in alarm management nationwide, and seeking standardization where possible. Members come from all aspects of alarm management: the clinical community; industry; device regulators; hospital accreditors; and professional societies.

For more information on the National Coalition for Alarm Management and this month’s presentation, please click here.

Understanding healthcare’s top technology hazard
September 4, 2014

“Even with some of the world’s top device manufacturers (General Electric, Phillips, Stanley, Medline, etc.) working to develop “smart alarm” systems, the dangers are still very real. On the Emergency Care Research Institute (ECRI) Top 10 Health Technology Hazards for 2013, alarm hazards ranked number one. The issue of alarm fatigue has many facets.”

For the article, please click here.

Joan Rivers’ Death
September 12, 2014

What Killed Joan Rivers? Piecing Together a Medical Mystery

Dr Karen Sibert offers a thoughtful discussion that raises questions and offers useful information about routine procedures. As she observes, “There are minor operations and procedures, but there are no minor anesthetics. This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers.”

4 Lessons Learned from the Death of Joan Rivers

This article we co-authored with Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (Baltimore, MD). It offers 4 lessons to be learned from the death of Joan Rivers that can help others better prepare for safe medical procedures.

Capnography Outside the Operating Rooms
September 19, 2014

This article in Anesthesiology, “Capnography Outside the Operating Rooms” written by Dr Bhavani Kodali (Associate Professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School), sheds light on capnography outside the operating room.

Alarm Fatigue – Not Just an Annoyance to Nursing Staff
September 26, 2014

Hats off to @DicksonData for pointing out this article that reminds us that “noise is an environmental stressor that can have physiological and psychological effects” on patients.

C-section America’s most common major surgery?
October 3, 2014

Hats off to @JuanGrvas for asking “How did the C-section become America’s most common major surgery?” and pointing out this video by Chileshe Nkonde-Price, a cardiologist at the University of Pennsylvania, who wants to avoid an unnecessary C-sections.

Helping Hospitals Fight The Battle Against Alarm Fatigue
October 17, 2014

Robert J. Szczerba’s Forbes article made waves as it looked at alarm fatigue. As Szczerba notes:

“One of the top technologies hazards in the healthcare system is the problem of alarm fatigue, in which the sheer number, variety, and frequency of machine alarms in a hospital room leads to many of them being ignored or muted. The negative results range from annoyance to patient deaths.”

To help reduce alarm fatigue, we offer advice from members of our advisory board:

Actions Produce Results
October 24, 2014

Hats off to @TGandhi_NPSF for tweeting about this study about the affects of rounds, culture, and caregiver burnout. If leaders want to change culture and behavior, they need to be involved.

“We can’t always predict when a patient will slip from moderate sedation to deep sedation”
October 31, 2014

In this Wall Street Journal article, our own advisory board member, Frank Overdyk, MSEE, MD (Executive Director for Research, North American Partners in Anesthesiology; Professor of Anesthesiology, Hofstra North Shore-LIJ School of Medicine) reminds us:

We can’t always predict when a patient will slip from moderate sedation to deep sedation,” he says, and if the staff is unaware or inexperienced, and help isn’t available to deal with breathing and airway issues, a patient can suffer an oxygen-related brain injury “in approximately five minutes.”

Death During Childbirth
November 7, 2014

ABC news reports that “Kymberlie Shepherd, 26, died shortly after giving birth … The cause of her death was a rare amniotic fluid embolism (AFE), a leading cause of maternal mortality in the developed world.”

Kymberlie Shepherd

(Kymberlie Shepherd with her fiancé, Wayde)

Observational study counts alarms in ICUs to better understand alarm fatigue
November 21, 2014

The number of alarms collected during one month in five ICUs is “staggering” according to researchers who found that, in nearly 50,000 hours, 2.5 million unique audible and inaudible alarms occurred. The research calls for smarter monitors.

Also, hat tip to @Krista_Bones for sharing this article in Fierce Healthcare. Some good commentary by Krista, who points out that patients and families get fatigued from all the alarms—not just clinicians.

Make Health Technology Safer
November 28, 2014

In this interview with Institute for Healthcare Improvement Executive Director and patient safety expert, Frank Federico, RPh (who we are proud to say is on our advisory board) offers these tips to make health technology safer.

1.3 million adverse events prevented since 2010
December 5, 2014

The Agency for Healthcare Research and Quality (AHRQ) estimates that 1.3 million fewer patients were harmed in U.S. hospitals from 2010 to 2013. AHRQ attributes this to “focused and widespread efforts to reduce surgical-site infections, adverse drug events and other preventable incidents.”

Modern monitoring systems contribute to alarm fatigue in hospitals, UNC study shows
December 12, 2014

Hats off to @UNC for an example of winning the battle against too many alarms.

The Value of Safer Care
December 19, 2014

A survey by Altarum Institute and Drexel University found that “most respondents would choose a hospital with a higher patient safety rating, even if it meant paying an additional $1000 in out-of-pocket costs.”

Capnography, Patient Monitoring, Patient Stories

Patient Stories Shared at First Meeting of National Coalition to Promote Continuous Monitoring of Patients on Opioids

The Physician-Patient Alliance for Health and Safety today released the patient stories it shared at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids.

“We hope that the adverse events and deaths of patients who have suffered opioid-induced respiratory compromise may serve as inspiration to encourage the adoption of continuous electronic monitoring of all patients receiving opioids,” said Physician-Patient Alliance Executive Director and Founder Michael Wong, JD.

In particular, two moving stories were shared at the inaugural meeting.

Brian Abbiehl, who is on the board of directors for Physician-Patient Alliance, recounted the tragic events leading to the death of his daughter Amanda. Along with his wife Cindy, Brian established A Promise to Amanda Foundation as a tribute to Amanda, and to educate patients and their loved ones about the need for continuous monitoring of patients receiving opioids.

Retired Michigan State Trooper Matt Whitman shared his own experience with opioid-induced respiratory compromise that nearly claimed his life.

For a full copy of all of the stories shared with the meeting’s attendees, please click here.

Capnography, Patient Monitoring, Patient Safety, Patient Stories

Sleep Apnea + Opiods = Post-Surgical Preventable Death

[Editor’s note: This article first appeared in The Doctor Weighs In. The team at Physician-Patient Alliance for Health & Safety thank Pat for her tremendous courage and working with us on this tragic story of what happened to her husband. We hope that in this retelling, hospitals will be encouraged to ensure that similar events become “never events”.]

By Patricia LaChance

After undergoing what most people would consider a routine surgery, my husband John, died. Just as heartbreaking as John’s passing was to me is the fact that his death was entirely preventable.

Please click on the picture to view the video about John.

Please click on the picture to view the video about John.

John died because his medical history was ignored and because he was not properly monitored after he was placed on a strong narcotic to ease the pain from his surgery to repair a torn rotator cuff in his shoulder.

That is the simple version of John’s story, but of course, there’s much more to it than that. Since he left us in March of 2007, I have come to learn a lot about what caused his death, and I want to share my experience so that other families, nurses, doctors and hospitals can prevent what happened to him.

John suffered from sleep apnea, which John and I thought at the time was merely a sleep issue. We had no idea it could also be a fatal issue.

John underwent two surgeries. His first was a same day surgery. After this first procedure, he experienced a great deal of trouble recovering from the anesthesia. He struggled for hours to wake up enough to be able to leave the hospital.  He was very groggy, nauseated and dizzy.

During the months that followed, he struggled with similar side effects from several narcotics that were prescribed for his pain management. He had two severe episodes at work – one he was able to sleep off at home; the other required an ambulance ride to the emergency room.

Six months later, John’s shoulder injury required a second repair. Immediately following this second surgery, John — like millions of Americans who undergo surgery — was placed on patient-controlled analgesia (PCA), commonly known as a “pain pump” that intravenously delivered opioid medication to help him manage his pain. We were familiar with PCA, but unaware of the dangers associated with it.

Prior to and following John’s second shoulder surgery, I discussed his opioid-intolerance and sleep apnea with all of his caregivers, but he was nevertheless placed on PCA. Once again, his body rejected the medication and became extremely ill.

Observing John’s discomfort, a nurse disconnected him from the PCA pump and directly administered Dylaudid, a stronger opioid. With the removal of the PCA pump, the Pulse Oximetry and supplemental oxygen were also removed. Within minutes, he seemed to be comfortable – comfortable to the point that he did not move or speak to me again – he just stared at the ceiling. I was concerned about his condition, but the nurse was not.

Thinking John was finally going to get some much needed rest at the end of a trying day, I kissed him on the forehead, told him that I loved him, and promised to return first thing in the morning to take him home.

But that isn’t what happened. In the early hours of the morning, John passed away.

With all my heart, I wish I had known that night what I have come to understand today: Patients receiving opioids after surgery – especially those with sleep apnea – are at very real risk of fatal respiratory depression.

That’s exactly what happened with John. He fell into a deep sleep, and was not able to awake. Because he was not monitored, his caregivers had no idea that he was in trouble.

This did not need to happen. If the hospital had used technology such as capnography and pulse oximetry to continually monitor John’s respiratory status, he would still be with me today.

John meant the world to me, our children and his family, and many friends. Together, we sincerely hope that other families never have to go through what we did. For that to happen, I strongly believe that there are two critical patient safety issues that our nation’s hospitals must immediately address:

  1. In far too many instances, post-surgical patients are placed on opioid therapy with little or no consideration given to their medical histories, especially as they relate to medication tolerance. When I recently spoke to the Maryland Association of Nurse Anesthetists, one of the points I made was that each individual patient needs to be assessed for medication intolerance. Not all patients can tolerate the same medications. Yet, my observation is that far too often, opioids are automatically the medication of choice, and the patient’s medical history is not taken into consideration. My husband is a prime example.
  1. Continuous monitoring of all post-surgical patients receiving opioids should be a national standard of care. Recently, the Centers for Medicaid Centers for Medicare & Medicaid Services (CMS) issued guidance recommending that patients receiving opioids after surgery should be continuously monitored for signs of respiratory depression.

The CMS guidance perhaps summarizes this best when it states:

Each year, serious adverse events, including fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid-induced respiratory depression has resulted in patient deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient’s respiration rate, oxygen and sedation levels. Hospital patients on IV opioids may be placed in units where vital signs and other monitoring typically is not performed as frequently as in post-anesthesia recovery or intensive care units, increasing the risk that patients may develop respiratory compromise that is not immediately recognized and treated.



Capnography, Monitoring Liability and Costs, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

A Decade of Excellence: Hospital Celebrates 10 “Event Free” Years of Patient Safety

By Briggs Adams (Editorial Manager, Physician-Patient Alliance for Health & Safety)

When the leader of St. Joseph’s/Candler Hospital respiratory therapy team was initially considering using capnography to monitor patients receiving opioids after surgery, he predicted the outcome would go in one of two ways.

“Quite honestly, we thought capnography was either going to be tremendously successful or a complete disaster,” said Harold Oglesby, Registered Respiratory Therapist (RRT), Manager, The Center for Pulmonary Health, Candler Hospital, and St. Joseph’s/Candler Health System (SJ/C).

Harold Oglesby - Celebrating 10 Years's Event Free

(for the Georgia Hospital Association video awarding Harold Oglesby the “Hospital Hero” award, please click the picture)

Disaster never struck. And it’s been averted for more than a decade, which demonstrates a high level of clinical achievement.

In fact, since Mr. Oglesby and his respiratory therapy (RT) staff decided to use capnography to continuously monitor patients receiving patient-controlled analgesia (PCA) in June 2004, SJ/C has been “event free” in terms of opioid-related adverse outcomes. As a result, the Savannah, Georgia hospital has become a role model for hospitals across the nation to institute this type of “best practice”. This has prompted many to consult with Mr. Oglesby to gain his insights on how to achieve similar success with capnography monitoring at their respective institutions.

“I’ve had several nursing directors, RT directors and other hospital staff reach out to me, and we’ve helped them bypass some of the pitfalls,” he said.

SJ/C’s journey to perfection began on a relatively small scale, with a six-month beta test in which new PCA and monitoring modules were integrated with the hospitals existing IV safety platform. A small group of patients were selected for the pilot test.

During the test, the team gained invaluable insights not only into capnography, but also into alarm management. Among the important lessons learned, Mr. Oglesby said, was that “the team recognized that the safe use of PCA requires correct pump programming, along with monitoring of the patient’s individual respiratory response to opioids.”

Another key learning, he said, was that early in the decision-making process, SJ/C found that having the respiratory care team intrically involved was critical.

“Respiratory therapists have strong clinical assessment skills, they understand capnography monitoring and its limitations, and they are able to apply solid clinical judgment as they guide the care of patients suffering from respiratory issues,” Mr. Oglesby said. He added that it was equally critical for the nursing staff to have an active role in the pilot test, because it ultimately increased the staff’s knowledge and enthusiasm for using the new technology.

After the beta test was completed, SJ/C concluded that capnography, not pulse oximetry, provided the first indication of opioid-related respiratory depression. As a result, SJ/C now requires that capnography module be used for all PCAs infusions and pulse oximetry modules for selected PCA patients with pre-existing comorbidities.

Though it was used on a small scale 10 years ago, capnography has become widespread at SJ/C. The monitoring technology is now utilized for both non-intubated and intubated patients, in the ICU, on the general floor wherever patients are receiving opioids, in the emergency room and for patients who are having procedural sedation, Mr. Oglesby said.

As capnography grows more pervasive at SJ/C, so, too, does the possibility for an adverse event. But thanks to the constant vigilance of the RT team, the hospital remains “event free.”

“Whenever we find ourselves becoming complacent, we remind ourselves how important it is what we’re doing,” he said.

In addition to the enthusiasm that SJ/C’s caregivers have for capnography, patient education has played a critical role in helping the hospital prevent adverse events, Mr. Oglesby said.

When patients and their families understand the benefits of capnography and that it’s being used for their safety, they’re much more compliant and willing to wear the cannula,” he said.

Ten “event free” years at SJ/C has not only delivered immeasurable value in protecting the lives and safety of numerous patients, but also hard-dollar patient-care savings. The hospital’s estimates show that by implementing capnography for PCA patients, it saved nearly $4 million dollars between 2002 and 2007.

Understandably, the RT team takes considerable pride in its decade of perfection, but as Mr. Oglesby pointed out “It’s first and foremost a victory for the patient.”

Capnography, Patient Monitoring

Monitoring for Respiratory Compromise to Detect Cardiac Arrest

In his op-ed, Lakshmipathi Chelluri, MD, MPH (Professor, Department of Critical Care Medicine, Co-chair, P&T Committee, UPMC Presbyterian, University of Pittsburgh School of Medicine), asks a great question “Preventable In-Hospital Cardiac Arrests―Are We Monitoring the Wrong Organ?[1]

To help prevent the onset of cardiac arrest, Dr. Chelluri suggests that clinicians should be monitoring for respiratory compromise as a key trigger or potential alert for cardiac arrest.

To understand this proposition better, I asked Dr. Chelluri a number of questions. I hope that you will find this discussion to have high clinical value and interest. The actual implementation of them could significantly save patients’ lives:

Q: To detect cardiac arrest, isn’t electrocardiography (ECG) monitoring the accepted practice?

A: ECG monitoring is used extensively outside of ICU. However, recent research has looked at cardiac arrest outcome and continuous ECG monitoring, and found that many patients are receiving ECG monitoring unnecessarily.[2] Cardiac monitoring has been shown to be ineffective in identifying patients at risk for respiratory deterioration and cardiac arrest as result of respiratory arrest. With this knowledge, we need to be asking ourselves what monitoring might be better at detecting the onset respiratory deterioration. I would suggest that that monitoring should be respiratory monitoring.

Q: Why do you think that respiratory monitoring might detect and possibly prevent cardiac?

A: Many cardiac arrests have a respiratory origin. To do understand this better, we need to consider the etiology of cardiac arrest. Primary etiologies consist of a cardiac disease, such as ischemia or failure, causing ventricular fibrillation/ventricular tachycardia. Secondary etiologies consist of non-cardiac events, hypoxia and respiratory failure.1 These non-cardiac events are respiratory in nature, may cause asystole (commonly known as an incident when the patient ”flatlines”) or pulseless electrical activity (in which electrical activity is detected in the heart, but the heart does not contract to generate a pulse). Secondary cardiac arrest is often related to hypoxia or fatigue/hypercarbia, which may lead to respiratory compromise followed by tachycardia, bradycardia and cardiac arrest. Distinguishing between these two etiologies may therefore help us to increase focus on respiratory monitoring and prevent cardiac arrest in some patients.

Q: To help detect secondary cardiac arrest due to respiratory compromise, what respiratory monitoring would you currently recommend?

A: Current respiratory monitoring systems available for prevention of secondary cardiac are pulse oximetry and capnography monitoring. Pulse oximetry measures the oxygenation of blood and is widely use. However, pulse oximetry is a lagging indicator to detect fatigue and respiratory compromise. Capnography measures the amount of carbon dioxide in exhaled breath and is a better indicator of the adequacy of ventilation of the patient. However, capnography monitoring does have its own limitations. Most particularly, making sure that the nose cannula actually stays on the patient, as measurement depends on accurately sensing the flow. Improving capnography technology and multimodal monitoring (respiratory rate, pulse oximetry and capnography) could identify patients at risk of respiratory deterioration and progression to cardiac arrest.


Chelluri, L. (2014) Preventable In-Hospital Cardiac Arrests―Are We Monitoring the Wrong Organ? Open Journal of Emergency Medicine, 2, 43-45.


[2] Henriques-Forsythe, M.N., Ivonye, C.C., Jamched, U., Kamuguisha, L.S.K., Olejme, K.A. and Onwuanyi, A.E. (2009) Is Telemetry Overused? Is It as Helpful as Thought? Cleveland Clinic Journal of Medicine, 76, 368-372.

Schull, M.J. and Redelmeier, D.A. (2000) Continuous Electrocardiographic Monitoring and Cardiac Arrest Outcomes in 8,932 Telemetry Ward Patients. Academic Emergency


“Keep It On” Campaign: 8 Tips for Ensuring Children are Monitored Safely

By Lynn Razzano RN, MSN, ONCC Clinical Nurse Consultant for PPAHS

The Physician-Patient Alliance for Health & Safety was recently contacted by a mother whose one-year-old baby boy tragically passed away. The boy suffered from leukemia, had a successful bone marrow transplant, and had received fentanyl and methadone. Although monitored with a pulse oximeter, his nurses had difficulty keeping the monitor on his finger (they had used tape), which caused the oximeter to false alarm frequently and the alarms to be turned down.

There were other issues involved with the boy’s care, but below are offered 8 tips for ensuring children are monitored safely:

  1. In applying and maintaining accuracy of pediatric pulse oximetry, it is critical to ensure you have the necessary equipment on hand that is pediatric specific. There should be an adequate supply for each child with enough excess so as to change the oximetry monitor when needed. This should be the first action step on a pediatric unit that requires monitoring for pulse oximetry.
  2. The pulse oximetry should be applied to the finger and fit securely to ensure the oximeter is accurately monitoring the child. In doing this, please keep in mind:
    • Overuse of tape to keep the device on is a common error. The more tape you use the stickier the surface gets over time. This causes loosening of the oximetry device as the stickiness attaches to sheets whenever the child moves his hand or arm. This will ultimately cause a disconnect that may not be picked up readily.
    • If the child does not tolerate the finger and pulling at the device or hand/arms are in motion then apply to the great toe. This will adequately provide effective monitoring in lieu of the finger placement.
  3. Even though clinicians want their patient to have undisturbed sleep, do not silence the alarm for any reason. This leads to an unmonitored patient who may become in distress in a matter of seconds. When rounds occur, the alarm volume should always be checked and documented that it is on and not turned down. Audible volume is critical here to alert caregivers at the earliest moment to the onset of respiratory compromise.
  4. Alarm parameters should be double checked by two nurses before any changes and the physician order sheet should be checked for confirmation of the actual parameter. If the patient is on opioids, no matter the dose, the pulse oximetry device should be on the child and a baseline oxygen level should be checked and documented before administration of any opioid.
  5. Pharmacy should be double-checking, as well as two nurses, before a dose of opioid is given to a child. The child’s accurate height and weight should be recorded in the medical record. If there is any question about the pediatric dose ordered, a call to the pharmacy should be initiated and a pharmacist should confirm this is the correct dose to administer to the patient. This may appear to be redundant and unnecessary but extra caution and safety is key here to prevent a respiratory adverse event or untimely preventable death of a child who has received the wrong dose of opioid.
  6. Narcan should be in the room in a visible site for all pediatric patients receiving opioids and the actual pediatric dose of Narcan to be administered should be next to the vial in the patient’s room.
  7. Demonstrated nursing education and competencies in the application of the pulse oximetry device should be ongoing and validated with no exceptions. This ensures the staff is competent in continuous electronic monitoring of the pediatric patient.
  8. Post clinical tips at the nurses’ station, in the unit, and perhaps even in the patient’s room.

Starting a ”Keep It On” Campaign for proper securing of pulse oximetry monitoring is a safe practice easily initiated. Buy in from all staff on the unit may prevent an untimely adverse event or death that could have been easily prevented, like that of the one-year old baby boy. An ounce of prevention is worth this extra effort in performance improvement and safe practice in monitoring the pediatric patient receiving opioids.

Please let us know of any tips you may have.

Capnography, Patient Safety

Weekly Must Reads in Patient Safety (Sep 19, 2014)

As you may be tired of reading about the death of Joan Rivers, we thought that we’d highlight some important practice recommendations instead …

… and then just one article on Joan Rivers. Not only is the article in Gastroenterology & Endoscopy News, but Kenneth P. Rothfield, MD, MBA (chairman of the Department of Anesthesiology at Saint Agnes Hospital) is quoted in this article. Dr Rothfield is on our board of advisors, so we must confess that we are biased towards his passion and commitment to patient safety.

Clinical Practice Guidelines for Prevention and Treatment of Pressure Ulcers

National Pressure Ulcer Advisory Panel recently released Clinical Practice Guidelines for Prevention and Treatment of Pressure Ulcers. Please click here for a copy.

Updated Opioid Toolkit to Include Naloxone Recommendations

The Substance Abuse Mental Health Services Administration (SAMHSA) recently updated its opioid toolkit to include naloxone recommendations.

5 Anesthesia Tests to Avoid

JAMA Internal Medicine recently released 5 specific tests or procedures commonly performed in anesthesiology that may not be necessary – do you agree or disagree?

Capnography Outside the Operating Rooms

Hats off to @Anaesthesia_AGB for tweeting about this article in Anesthesiology, “Capnography Outside the Operating Rooms” written by Dr Bhavani Kodali (Associate Professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School)

Clinic in RiversDeath Denies Biopsy Claim

It’s unclear if the doctors attending Ms. Rivers deviated in any way from their normal protocol, but treating a famous person may pose an added stress, Dr. Rothfield explained. Gastroenterology & Endoscopy News probably should have mentioned Dr. Rothfield’s article on “4 Lessons Learned from the Death of Joan Rivers” … so, we’ll do it here.