
On July 23, 2007, my 17-year-old son, Logan Parker, underwent successful surgery at a freestanding ASC to correct his sleep apnea. He received IV morphine in the PACU: 2 mg administered 3 times over 20 minutes beginning at 12:50 p.m. His IV was removed 8 minutes later and he was discharged at 1:25 p.m., just 15 minutes after his last dose. A few hours later, as he recovered at home, Logan stopped breathing. Although I'm a recovery room nurse at a local hospital, I never imagined my son would become my patient. I immediately began to perform mouth-to-mouth resuscitation. A few minutes later, Logan's heart stopped and I began chest compressions until the paramedics arrived. They intubated him on the floor of my living room before transporting him to a local hospital.
We followed the ambulance to the hospital, where we were allowed into the trauma room. The attending physician said he wanted us to sit next to Logan, to talk to him. His father was on his left side, just sobbing, and I was on his right side pleading with him to try harder and to hang on. I rubbed his face and his arms. I told him how much I needed him. Then the doctor told us that there wasn't anything they could do to make Logan's heart start again. I let out a very loud wail that frightened even me. The doctor put his hand on my shoulder and told me that it was time to say goodbye. Logan died just 2 weeks before his senior year of high school, the victim of opioid-induced hypoxia.
Now that it's been over 9 years since Logan slipped out of my hands, I have a clearer understanding about the changes that need to occur as healthcare providers continue to strive for zero patient harm. The memory of Logan and the desire to prevent another mother from experiencing the devastation I have endured has inspired me to come up with these 3 keys to improving patient safety.
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