Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 3)
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"Medical errors are now
the third leading cause
of death. We no longer
have the luxury of
believing it could never
happen to me."
- Lenore Alexander,
mother of daughter who
died in the hospital
that it was a lack of continuous monitoring
that ended their child's life?"
"I want a standard of care that uses the
existing technology to create a new standard
of safety. Because medical errors happen to
one person at a time, behind closed doors,
it's easy for people not to pay attention. But
medical errors are now the third leading
cause of death. We no longer have the luxury
of believing it could never happen to me. We
need to be engaged, educated and smart
patients. My part in this is making sure
continuous electronic monitoring for all
patients on opioids is the standard of care in
every hospital in America."
John LaChance:
Rotator Cuff Surgery
Risk Factors: Sleep apnea, previous
problems with pain management
In March 2007, Patricia LaChance accompanied her husband of 27 years, John Michael
LaChance, to a hospital in Fredericksburg,
VA, for routine rotator cuff repair surgery. He
had re-injured his shoulder when he reached
out to block a basketball from hitting Patricia
during an event at their church. Since he had
experienced adverse reactions to pain
medication with an earlier surgery for the
same rotator cuff problem, his surgeon
recommended a 23-hour hospital stay for
pain management. In addition, John was
previously diagnosed with sleep apnea. He
and Patricia shared this information with the
medical team prior to surgery, but a continuous positive airway pressure (CPAP) machine
was not ordered for him to use after surgery.
To control his pain during surgery, he
42
received a shoulder block, a form of local
anesthetic. After surgery, doctors prescribed
morphine through a patient-controlled
analgesia (PCA) machine, along with monitoring via pulse oximetry. The morphine did
not manage his pain but instead caused
extreme vomiting. John was removed from
the PCA machine as well as the supplemental oxygen he had been receiving and instead
given an injection of Dilaudid for pain along
with an anti-nausea medication. He was also
removed from the pulse oximeter that had
been monitoring his oxygenation levels while
on the PCA machine.
"Shortly after, John seemed to be sleeping
well so I went home for the night with the
intent of taking him home the next morning," says Patricia. When she left at 10 p.m.,
John was snoring. He was in a room by
himself at the far end of the hallway. Patricia
never got the chance to take him home. After
a second dosing of Dilaudid sometime
during the night, a nurse making rounds at
4:20 a.m. found John unresponsive in his
bed. The crash team worked on John for
more than 40 minutes, but he died.
"Why was John removed from monitoring
when they began administering stronger
opioids?" asks Patricia. "That was the standard
of care for post-orthopedic surgery patients.
But now we're finding out how important it is
to remain monitored. His sleep apnea
diagnosis was really a respiratory issue, and
when mixed with opioids, that diagnosis puts
patients at a much higher risk for respiratory
depression. Each patient, each person, has
different needs and issues. Blanket care orders
don't work for everybody."
"I don't want any other family to go through
this," she says. "I continue to be shocked as I
learn of the deficiencies within our healthcare
systems and in our healthcare providers when
it comes to understanding the dangers of
these drugs and the importance of continual
monitoring." "How can patients and their
families be expected to understand and
monitor these things when even our healthcare providers don't?" she asks.
Biomedical Instrumentation & Technology January/February 2015
Table of Contents for the Digital Edition of Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 1)
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 2)
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 3)
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 4)
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 5)
https://www.nxtbook.com/allen/bmit/january-february-2015-40
https://www.nxtbook.com/allen/bmit/november-december-2013-467
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