Physician-Patient Alliance for Health & Safety: Patient Death in California is a Wake Up Call for Standards

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The California Department of Public Health (CDPH) recently reported the death of a patient following a surgical procedure on his heel who used patient-controlled analgesia to manage his pain. The CDPH report indicates that the hospital did not have a PCA policy. Hospitals are encouraged to standardize PCA practice and have a PCA policy. One starting point is the recently released PCA Safety Checklist.

Hospitals are encouraged to standardize PCA practice and have a PCA policy. One starting point is our recently released PCA Safety Checklist.

The California Department of Public Health (CDPH) recently reported the death of a patient following a surgical procedure on his heel.

In that case an opioid-naïve patient received an estimated total dose of 67.8 mg of morphine delivered by patient-controlled analgesia (PCA) over an 8-hour period following a surgical procedure on his heel. He was found unconscious and not breathing in the early morning hojurs and could not be resuscitated.

The CDPH report indicates that the hospital did not have a PCA policy.

Says Michael Wong, executive director of the Physician-Patient Alliance for Health & Safety (PPAHS), “Hospitals are encouraged to standardize PCA practice and have a PCA policy. One starting point is our recently released PCA Safety Checklist.”

The PCA Safety Checklist was developed with a group of a renowned physicians and nurses and can be downloaded for free off of the PPAHS. The link can be found in the upper right hand corner at http://www.ppahs.org

Additionally, as noted in the recent analysis of this case by Dr. Bradley Truax, who is board certified in neurology and internal medicine, this case unfortunately demonstrates a number of procedural flaws:

  •     Treatment for opioid-naïve patients, usually begins with a lower starting dose of morphine, which is titrated upward as needed for pain control. Additionally, basal infusions in opioid-naïve patients are usually not recommended.
  •     It also does not appear that electrocardiographic monitoring or capnography were used.

For a complete copy of Dr. Truax’s analysis, please go to: http://ppahs.org/2013/03/27/understanding-adverse-events-and-death-root-cause-analysis-of-california-department-of-public-health-case/

About PPAHS

The Physician-Patient Alliance for Health & Safety (PPAHS) is an advocacy group devoted to improving patient health and safety. PPAHS supporters include physicians, patients, individuals, and organizations.

PPAHS recently released a concise checklist that reminds caregivers of the essential steps needed to be taken to initiate Patient-Controlled Analgesia (PCA) with a patient and to continue to assess that patient’s use of PCA. For more information and to download the PCA safety checklist, please visit http://www.ppahs.org

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