Amanda was 18-years-old when she was admitted to hospital for a severe case of strep throat on July 15, 2010. To help her manage the pain, she was placed on a patient-controlled analgesia (PCA) pump. The next morning, she was found unresponsive and died. Though PCA pumps are designed to deliver an exact dosage of opioid - in Amanda's case, hydromorphone - getting the 'right' dosage is not a simple task. Too high a dosage can lead to respiratory depression, sometimes in minutes.
"Amanda's story, and countless others like it, could have been prevented with the right policies and technology in place," says Michael Wong, JD, Founder & Executive Director of PPAHS. "It's a powerful reminder of our need for continuous electronic monitoring for patients receiving opioids in hospital to ensure caregivers are notified of any deterioration so that appropriate intervention can be taken."
PPAHS highlights that undetected opioid-induced respiratory depression remains an ongoing public health issue. ECRI Institute - a nonprofit with a mission to use applied scientific research to determine best practices in medical procedures, devices, drugs - has placed the issue as number 4 on its Top 10 Health Technology Hazards for 2017. Opioid-related harm has been targeted by ECRI's annual list for consecutive years.
PPAHS has recently published a position statement calling for the use of continuous electronic monitoring, such as pulse oximetry to measure oxygenation and capnography to measure the adequacy of ventilation, to detect the early signs of opioid-related respiratory depression. Amanda was placed in a general ward with only intermittent spot checks from clinicians on rounds, which was not sufficient to detect an opioid overdose before it was too late.
The organisation has also developed a PCA Safety Checklist in collaboration with a panel of medical experts including intensive care specialist and a leader in medical checklist development Peter J. Pronovost, MD, PhD, FCCM, Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient; and Atul Gawande, MD, Professor in the Department of Health Policy and Management at the Harvard School of Public Health, who is a surgeon at Brigham and Women's Hospital Professor of Surgery at Harvard Medical School and author of "The Checklist Manifesto." The checklist is available as a free PDF download on the PPAHS website.
A foundation in Amanda's name has been created by her parents, Cindy & Brian Abbiehl. To learn more about Amanda's story and PCA safety, please visit the Promise to Amanda website.
About Physician-Patient Alliance for Health & Safety
Physician-Patient Alliance for Health & Safety is a non-profit 501(c)(3) whose mission is to promote safer clinical practices and standards for patients through collaboration among healthcare experts, professionals, scientific researchers, and others, in order to improve healthcare delivery. For more information, please go to www.ppahs.org.
SOURCE Physician-Patient Alliance for Health & Safety