Patient Monitoring

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.”

Checking Fridge Light

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

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

Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Jan 30, 2015)

At a conference, clinicians were arguing about the use of technology – some wanted to use it, others wanted to wait until something better came along. The latter group was willing to risk ore adverse events and deaths, while “waiting” it out … although one wonders if they would feel this way if the life of a loved one was on the line …

We think we should make the best use of what we have and save lives now.

To improve patient safety, perhaps we just need to get smarter.

Smarter About Treating Pregnant Mothers

Joanne Jones family

This father and his children are now without a wife and mother, after the mother, Joanne Jones, suffered from a massive blood clot after safely delivering her son Riley.

We need to get smarter about using available information.

Would the use of the OB VTE Safety Recommendations, which we released with the Institute for Healthcare Improvement and the National Perinatal Association, have prevented the blood clot and saved Joanne Jones’ life?

Smarter About Monitoring Patients Receiving Opioids

The Physician-Patient Alliance for Health & Safety recently issued the following statement encouraging the continuous electronic monitoring of all patients receiving 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.

Thanks to @Brian_Wellons and @yesmedical for tweeting about this.

We need to get smarter about the use of respiratory monitoring technology – like pulse oximetry and capnography.

Smarter About the Use of Opioids

A recent study looked at data of nearly 57 million American women who were admitted for obstetric delivery between the years 1998 and 2011. The researchers found that “opioid abuse or dependence during pregnancy (n= 60,994) markedly increased the odds of obstetrical mortality.”

We need to get smarter about the use of opioids.

As Gina Pugliese, RN, MS (Vice president, Premier Safety Institute) recently remarked in commenting on a study looking at opioid use in common pediatric surgeries:

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.

Smarter About the Use of Nurses

Researchers recently looked at in-hospital deaths in a thousand ICUs in 75 countries. A high nurse to patient ratio in intensive care units was independently associated with a lower risk of in-hospital death, according to results from a study involving more than a thousand ICUs in 75 countries. Concluded the researchers:

Time constraints related to a reduced nurse to patient ratio may increase the likelihood of mistakes by creating a stressful environment with distractions and interruptions that adversely affect quality of care.

We need to get smarter about the use of nurses.

Patient Monitoring, Patient Safety

Physician-Patient Alliance Recommends Continuous Respiratory Monitoring of All Patients Receiving Opioids

The Physician-Patient Alliance for Health & Safety today issued the following statement encouraging the continuous electronic monitoring of all patients receiving 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.

In Amanda's Memory, Always Monitor

The Centers for Medicare & Medicaid Services (CMS) issued on March 14, 2014 revised guidance, “Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids”.

The CMS guidance recommends “at a minimum” that hospitals “have adequate provisions for immediate post-operative care, to emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.”

In addition and more importantly, the CMS guidance necessitates monitoring for all patients receiving opioids when in hospital:

Narcotic medications, such as opioids, are often used to control pain but also have a sedating effect. Patients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. Timely assessment and appropriate monitoring is essential in all hospital settings in which opioids are administered, to permit intervention to counteract respiratory depression should it occur.

“In issuing this statement,” explains Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), “we are especially reminded of Amanda Abbiehl, Leah Coufal, John LaChance, and countless others who may still be alive today had they been continuous electronically monitored.”

Physician-Patient Alliance released these and other stories of patients who suffered opioid-induced respiratory depression at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids. For a full copy of all of the stories shared with the meeting’s attendees, please click here.

The CMS guidance provides increased vigilance to patients receiving opioids, particularly those patients receiving opioids postoperatively. CMS explains the reason behind the issue for this guidance:

 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.

Patient Monitoring, Patient Safety, Patient Stories, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Nov 7, 2014)

This week’s must-reads bring the worst possible news: patient deaths.

Death After Routine Teeth Extraction

Seven-year-old Tyneisha Bell died five hours after visiting the dentist for a routine procedure – three teeth extracted.

Tyneisha Bell

(To view the FOX news report, please click here)

For the procedure, Tyneisha was given general anesthesia.

Death During Childbirth

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)

Death Because of a Failure to Monitor and Rescue

In this emotional video about the death of her father, Annette Smith makes a plea for continuous electronic monitoring.

Curtis James Bentley

(Curtis James Bentley)

If you’d support Annette’s plea for continuous electronic monitoring, please support the work of the National Coalition to Promote Continuous Monitoring of Patients on Opioids and join the Respiratory Compromise Institute.

Patient Monitoring, Patient Safety, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Oct 31, 2014)

Good news and bad news.

Yes, there have been other things going on in healthcare other than Ebola-mania … thanks @sacbee_news for this illustration putting Ebola in perspective:

ebola comic

The Good News

First, we’ll start with the good news, because most people love a celebration.

In case you missed it, October 29 was World Stroke Day!

As well, in case you may have missed it, to prevent DVT in stroke patients, the recent landmark study Clots 3 led by Martin Dennis, MD (University of Edinburgh, Western General Hospital) needs to be read and followed.

In our interview for Practical Neurology, Dr. Dennis explained how he thinks Clots 3 will change clinical practice:

“CLOTS 3 showed for the first time that thigh-length IPC [intermittent pneumatic compression] reduces the risk of DVT after stroke, and moreover improved survival. Therefore, I would expect its use to increase rapidly. Certainly in the UK there are national programs to introduce IPC into all stroke units; national stroke audits are monitoring its use.

Could better preventive practice have helped prevent blood clots for this North Carolina mother? We would love to hear if you think that the OB VTE Safety Recommendations might have helped, as it did for this obstetric patient.

The Bad News

Not only are liability claims over $2 million against hospitals continuing to rise, but new research suggests that hospitals may be losing the battle to reduce readmissions, and UCSF researchers logged 2.5 million patient alarms in one month.

To top it off, the United States ranks last among wealthy nations in access to healthcare.

Moral of the Story

And, just because a good and bad news story needs a “moral” to the tale…

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.”

So, the moral of the story – make sure you or your patients are continuously monitored for oxygenation and ventilation when opioids are administered, as recommended recently by the Anesthesia Patient Safety Foundation.

Alarm Fatigue, Patient Monitoring, Patient Safety, Patient Stories, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Oct 24, 2014)

It’s National Healthcare Quality Week and National Respiratory Care Week!

However, according to Pascal metrics, there is no reason to celebrate. Studies show that a third of patients are harmed in U.S. hospitals and the consequent financial burden of this harm may run to over $100 billion annually.

John LaChance died of opioid-induced respiratory depression. His story is retold by his wife, Patricia LaChance, in this poignant plea for better patient assessment and use of continuous electronic monitoring.

So, in keeping with the theme of quality and more particularly the need for better quality in respiratory care, here are this week’s reads on how to improve the quality of healthcare.

Quality Improves When Doctors and Nurses Work Together

Thank you @Nursiverse for pointing out this article by @paulinechen on research that nurses and doctors working together in the obstetrics and gynecology unit of a hospital “resulted in a significant decrease in the number of adverse patient outcomes, like traumatic birth injuries, admissions to the intensive care unit and death”.

Interesting! But, isn’t that the same thing that parents teach their elementary children – play nice in the sand box?

Actions Produce Results

Want to be a leader? Act like one. The leaders that act are generally most admired than those that just lip service to principles.

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.

Don’t Get Caught Up in Crying Wolf

Great tweet @ECRI_Institute on this article that compares alarm fatigue with “crying wolf” – except for patients, the “wolf” could be an adverse event or death.

Strict Malpractice Laws Do Not Reduce Health Care Costs

Thanks @Paduda for pointing out this study.

According a RAND Corporation study published in the New England Journal of Medicine, laws that make it harder to sue physicians for malpractice do not reduce hospital emergency department care costs.

To Improve Quality, Data is Needed

To make changes that improve quality, data is needed. According to a recent survey, patient safety leaders lack detailed, real-time harm data.

Unfortunately, efforts to prevent the flow of data have been undertaken at CMS.

Revision notice: An earlier draft mistakenly included a link to apple.com. It has been replaced by the appropriate link. Our apologies.

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.

 

 

Patient Safety

Weekly Must Reads in Patient Safety (Oct 3, 2014)

Patient monitoring seems to be the flavor of the day in this week’s articles and tweets … so, remember to monitor – Keep It On!

That said, better alarm management is needed to encourage more use of continuous electronic monitoring – could a woman’s death be due to alarm fatigue, as reported by Outpatient Surgery?

However, when adverse events occur (such as when an alarm is ignored), should the individual or the systems or lack of systems be blamed?

Monitoring to Improve Patient Safety and Outcomes

There are two recent studies to read on the benefits of patient monitoring.

The first is a study by Paul Niklewski, PhD, of University of Cincinnati and his colleagues, which suggests that the area under the curve of oxygen desaturation may provide “more complete information on the characteristics of desaturation episodes, [which] could be a useful new tool for monitoring patient risk during procedures”.

The second is a study from the Department of Respiratory Medicine, Shanghai Pudong New Area People’s Hospital which found that volumetric capnography may distinguish between chronic obstructive pulmonary disease patients and normal subjects.

The key takeaway – Keep It On!

Thanks to @joannasapida for tweeting about and supporting this effort!

Better Alarm Management is Needed

Hats off to @OutpatientSurg for this article – Patient codes on the OR table. Was distracted doctoring and alarm fatigue to blame?

Thanks to @stephanieO69 for pointing out our national survey that found hospitals rank alarm fatigue as top patient safety concern.

Are People or Systems at Fault?

Hats off to @MarkGraban for reminding us that firing people may not be the right patient safety fix.

As well, before we blame people, @StopErroresMed points out this study that shows that having enough nurses with the right workload is also a key to keeping patients safe.

Patient Monitoring, Patient Stories

Medical Error Takes a Father’s Life: A Daughter’s Plea for Answers

By Annette Smith

My 65 year old father, Curtis James Bentley, died in a hospital, and yet almost two years after his death, I still do not know what happened to him. The hospital and my father’s physicians have not provided this information. Why?

Curtis Bentley

My father had recently undergone successful surgery to place a stent in his heart at Emory Healthcare. The procedure had gone well. I was told that he was “100% clear,” and he was discharged from the hospital and went home. However, a review of his discharge summary recently revealed he was sent home with eight abnormal blood levels. This was a beginning of his demise in my opinion.

While recuperating at home, he started bleeding. He was coughing up blood, having nose bleeds and blood was present in his stool and in the toilet.

I took him to the ER at Piedmont Henry Hospital, where he was diagnosed with a lesion in his colon and admitted to ICU. That was Friday, September 7, 2012. I left once on Saturday to get food and clothes in preparation for staying with him the entire weekend if need be. We were supposed to go fishing.

However, on Sunday morning, I woke up from dozing on and off. No one had been in my father’s room for the past two hours since 2 am. A nurse finally came into my father’s room around 4 am. It was very brief. After not checking him for two hours, you would think it would be more thorough. I took the opportunity to take a much needed break from my vigilance at my father’s bedside.

I went to the restroom, stopped at the snack machine, called my husband and sat for awhile in the waiting room. While I was away from my father’s room, I heard a Code Blue sound. At first I thought it was for him, but it was for the neighboring patient. I sat a little while longer, but then I had an uneasy feeling. Something told me to go check on him.

I went back and saw that the Code Blue was indeed for the neighboring patient and that many physicians and nurses had responded. However, no one was with my father.

When I walked in, I couldn’t see my father’s face right away. One leg was hanging out the bed. Embarrassed, I asked him what was he doing, but he did not respond. I asked him a second time as I was covering him up. The TV went to a commercial at that moment and the light hit his face which was down against the railing. He was positioned like he was trying to get out, perhaps trying to get help. When I looked closer, I saw that my father was taking his last breath. I knew immediately that it was his last breath, as my step father had died in my arms. Their last breaths were identical.

I ran out calling for help.

A nurse came. During this time I’m yelling, “Where were you, where were you?” One nurse had the nerve to tell me, “You need to calm down!” I told her, “Don’t tell me to calm down! Where were you? Why wasn’t a code called for him?” She had no answer.

I had been in the room with my dad. No nurse had been present. No machine had alerted them to his deteriorating condition. Someone should have seen him, visually, as recommended by the Institute for Safe Medication Practices.

My father was intubated and placed on life support. I found out by reading his medical records that he had gone into a coma, was brain dead, suffered paralysis and necrosis. No one at the hospital told me that. He was in a coma for seven days and he never came out of it. Research shows, those types of adverse events are sustained from going too long without oxygen. What happened to Curtis James Bentley from 4-4:45? Was he calling for me? This was a critical moment that was not documented and haunts me.

A day or so after the code, I talked to the charge/manager nurse about what her staff had done (or rather not done) on that awful morning. She brought one of her fellow nurses in as a witness, I guess. My sister was there, too. I explained to her that there was no one around when my dad coded. No one was at the station monitoring him, nor any of the other patients for that matter – all except for the neighboring patient for whom the Code Blue had been called.

The charge/manager nurse told me “Well, when our adrenaline gets going, our focus is on one patient.”

I took a deep breath. The tears started rolling. I asked her, “You mean to tell me, if you have 15 patients on ICU, they are going to go uncared for because your focus is on one patient!?” She couldn’t say a word. She knew that was the wrong thing to say. She had just admitted that they had neglected to treat my father, while attending to that one neighboring patient.

I told her she shouldn’t say that to people. Then she said, “I’m sorry; someone is supposed to be monitoring these patients at all times.” I expressed my guilt for leaving his side and she fed me this story about leaving her mother home alone. She died too. It brought no comfort to me. Not after what she had previously said.

During those next seven days, I talked to my father, because I was told the hearing is the last to go. I called to him. I begged him not to go. I finally said enough is enough. It took everything in me to sign the form to take him off life support. My oldest sister and I lay on his chest until … My baby sister and my best friend were there giving us much needed support. I had to endure those last breaths…one-last-time…

This nurse and her colleagues had dropped the ball. But, tragically, this was not a game – my father lost his life, because they dropped the ball.

Isn’t that why patients are admitted to the ICU, because they need and must receive constant intensive care second by second? And, in order to receive that intensive care, should his nurses have been watching him, rather than leaving him alone for more than two hours? Should they not have used available monitoring technology to alert them of his condition when they were not in his room assessing his condition? How did they know the neighboring patient had coded, but not my father?

My father did not receive timely care and rapid response – I was the one who found him unresponsive and alerted the nurses to his last breath. There were no monitors that could have and should have alerted his nurses that he was in trouble? Why?

I have asked the hospital and his physicians these and many other questions. I deserve an explanation. All families deserve an explanation when something happens to their loved one.

I feel betrayed by the hospital, his physicians and nurses. I entrusted my father into their care, and they don’t care enough to speak openly and honestly with me about what happened.

Must I sue the hospital just to find out?

I wonder how many out there have gotten a call in the night saying, we’ve done all we could do, but you really don’t know if they did. You weren’t there. Or you stepped away and suddenly they are gone. Just how much trust should we put in the hands of these doctors and nurses?

I want to bring awareness in the name of my father, Curtis James Bentley, to people who have loved ones in ICU, to take notes, get involved, and know every nurse, doctor, procedure, times, machine hookups, medications and everything about your loved ones. Don’t assume when you walk through the doors of a hospital, that your loved ones are in great hands. Know the hospital you are choosing for them. Know what their success rates, health grades and complaints are. Get involved!

Would my father be here today had the proper monitoring taken place? Sadly, I will never know…

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

PPAHS Mourns the Fourth Anniversary of the Passing of Amanda Abbiehl

by Sean Power
July 24, 2014

This past weekend (July 17) marks the anniversary of the tragic death of 18-year old Amanda Abbiehl, whose story serves as a powerful reminder of the need for continuous electronic monitoring.

Lynn Razzano, Clinical Nurse Consultant with the Physician-Patient Alliance for Health & Safety, offers an appeal to her clinical colleagues:

“On the four year anniversary of the untimely passing away of 18-year old Amanda, hospitals need to think of how this could have been actively prevented. My hope is that this promotes more vigilance in appropriately assessing a patient when opioids are in use and ensuring that all patients receiving opioids are continuously electronically monitored.

“The time is now to prevent death from opioid-induced respiratory depression. It is as easy as ensuring the order is placed for continuous monitoring whenever opioids are ordered. This should be the new current standard of practice and one that proactively prevents opioid deaths from occurring.”

Join us in making a #Promise to Amanda today.

Patient safety champions: Promise to do everything you can to make it mandatory at your hospital for all patients on PCA pumps to be continuously electronically monitored with capnography and pulse oximetry.

Nurses, physicians, and respiratory therapists: Encourage patients and families to share their experiences with respiratory monitoring. Promise to talk to decision makers about capnography and respiratory monitoring every chance you get. Use the PCA Safety Checklist before, during, and after initiating PCA treatment.

Hospital administrators: Build redundancies into the system. Mistakes are going to be made but adverse events are preventable. Monitor every patient and save lives. Tell us if your hospital monitors patients with capnography while they are connected to PCA pumps.

Patients and families: Come forward to share your story about capnography. Write, phone, or email your local congressperson about making zero preventable deaths a policy priority.

Read more about Amanda’s story at promisetoamanda.org or at WNDU’s latest coverage of the Promise to Amanda Foundation.