Must Reads

Patient Safety Weekly Must Reads (January 14, 2017)

This week in #patientsafety, we’re back in the swing of things. We bring you highlights from Joan Rivers’ death and subsequent lawsuit. We also released findings from our Orthopedic Safety Survey. From around the web, an orthopedic surgeon shares thoughts on how pain scores led to the opioid epidemic, a study looks at the impact of opioid policies, and ECRI Institute releases the 2017 Top 10 Hospital C-suite Watch List.


Highlights From Joan Rivers’ Death and Lawsuit. Based on discussions at a recent meeting of the American Society for Healthcare Risk Management (ASHRM) New Jersey chapter.

Orthopedic VTE Safety Report Now Available. We released findings from a survey on practical solutions to prevent venous thromboembolism (VTE) in patients undergoing hip and knee replacement.

From Around the Web:

Making pain a vital sign caused the opioid crisis. Here’s how. This orthopedic surgeon makes the case that, despite good intentions, making pain a vital sign was a disastrous mistake.

Measuring the Impact of Opioid Policies. Federal agencies have issued policies to curb the opioid epidemic. MedPage Today looks at whether these policies are making an impact.

2017 Top 10 Hospital C-suite Watch List. Number 2 on ECRI’s latest list is opioid addiction. The report posits what role technology can have in predicting the risk of addiction and relapse, as well as provides five action points for better opioid safety.

Blood Clots, Patient Safety

Orthopedic VTE Safety Report Now Available

The Physician-Patient Alliance for Health & Safety (PPAHS) released findings on practical solutions to prevent venous thromboembolism (VTE) in patients undergoing hip and knee replacement.

The survey gathered 41 respondents from across the United States and targeted experts in orthopedics. The majority of respondents indicated that they were either physicians (42.5%) or nurses (32.5%). Those who elected to identify themselves as “Other” largely fell within four self-identified professions: nurse practitioners, physical therapists, program managers, and pharmacists. About 3 in 5 respondents indicated that their primary work setting was in Orthopedics.

According to Michael Wong, JD, Founder and Executive Director of PPAHS:

“The survey indicates that awareness of the risks of VTE following orthopedic surgery are high. Patients go through at least one assessment screening for risk of VTE, with an average of two times. The clinical outcome goal should be targeted at 100% compliance with VTE risk assessment on admission (to establish a baseline) and at multiple points along the patient’s continuum of care until discharge.

“Of note is the level to which prescription for mechanical prophylaxis, such as intermittent pneumatic compression device, drops following discharge; from 78% prior to surgery to 43% prior to discharge. An analysis of the data shows that eligibility for such methods under Medicare Part B could be a key driver in this pattern, with respondents indicating that they would be 34% more likely to prescribe mechanical prophylaxis for their patients if it were covered by Medicare Part B.

“It is clear that the lack of coverage by the CMS has restricted physician options in preventing VTE upon discharge. Nearly seven in ten respondents indicated that they believed that the lack of coverage for mechanical prophylaxis after discharge under Medicare Part B was not in the best interest of the patient. This indicates a strong call from physicians and their patients is needed to have the ability to prescribe the appropriate method for preventing VTE in their patients on an individual basis.”

Download the full report here.

Hip and knee replacement surgeries are among the most commonly performed procedures in the US. About 1 million of these procedures are performed each year.

The 30-day readmission rate following hip and knee replacement is 4.3% and 3.9% respectively. The readmission rate rises to 7.8% 90-days after surgery.

In the past, PPAHS has brought together panels of health experts to develop free clinical tools regarding VTE, including the OB VTE Safety Recommendations and the Stroke VTE Safety Recommendations.


Must Reads

Patient Safety Weekly Must Reads (January 7, 2017)

Happy New Year!

With the holidays winding down, it has been a quieter week in #patientsafety. Nothing from PPAHS this week as we get back into the swing of things. From around the web, we’ve got two articles about patient safety in Canada, plus a look at opioid-related inpatient stays and emergency department visits by state.


Nothing this week!

From Around the Web:

1 in 18 patients experiences harm in Canadian hospitals. Good for benchmarking the USA against comparators.

How a little-known patent sparked Canada’s opioid crisis. An investigative piece about the opioid crisis in Canada.

Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014. This HCUP Statistical Brief presents data from HCUP Fast Stats on the national rate of opioid-related hospital inpatient stays and emergency department (ED) visits from 2005 to 2014.

Patient Safety

Top 10 Articles of 2016

Happy Holidays!

We’d like to wish you a safe and healthy 2017.

As we prepare for 2017, we reflect back on the top 10 articles from 2016.

Opioid Safety

  1. Physicians on Surgeon General’s Letter on Opioid Epidemic: Survey Results. The Surgeon General issued an Open Letter on the Opioid Epidemic. We looked into how clinicians and other patient safety experts felt about it.
  2. The U.S. Opioid Epidemic In Numbers. Related, Advance for Nurses generated an infographic summarizing your responses.
  3. 12 Years of Event-Free Opioid Use. In 2016, St. Joseph’s/Candler Health System celebrated 12 years free from Serious Adverse Events related to Opioid-Induced Respiratory Depression since the implementation of its continuous monitoring program.

Alarm Safety

  1. 3 Ways to Make Opioids Safer. Peggy Lange, RT, Director of the Respiratory Care Department at St. Cloud Hospital, discussed the importance of setting alarm thresholds for each patient in this podcast.
  2. Drawn Curtains, Muted Alarms, And Diverted Attention Lead To Tragedy In The Postanesthesia Care Unit. Sadly, alarms on the monitoring equipment used to alert healthcare professionals to changes in the patient’s cardiac and respiratory status were muted in one tragic death of a 17-year-old.
  3. A New Tool to Predict Respiratory Failure: An Interview with Hiroshi Morimatsu, MD, Ph.D. Could this multi-parameter indicator help counter alarm fatigue?

Bloot Clots Safety

  1. New PPAHS Campaign Targeting Orthopedic Venous Thromboembolism. VTE is the third-most prevalent reason for readmission after surgery, and about 1 million hip and knee replacement surgeries happen each year in the U.S.
  2. Physician-Patient Alliance Partners with World Thrombosis Day. As part of our new campaign, we partnered with World Thrombosis Day in 2016. Looking forward to working together in 2017.
  3. Why Bundled Payments for Joint Replacement May Be Risky for Patients. We took a look at whether patients are receiving evidence-based or reimbursement-based care under the Bundled Payments model.

Special Mention

  1. Why All Medical Schools Must Incorporate Quality Improvement and Patient Safety into Their Curriculums. This position by Molly Siegel generated plenty of engagement on the Twittersphere and is a theme that cuts across all of our priority areas.
Opioid Safety, Practices & Tips, Respiratory Compromise

Minnesota RTs Help Implement Continuous Capnography Program

peggy lange

Peggy Lange, BA, RRT (RT Department Director, St. Cloud Hospital in St. Cloud, MN)

A recent article published by the American Association for Respiratory Care (AARC) has highlighted how respiratory therapists (RT) can play an integral role in using capnography to detect the signs of respiratory depression.  The post focuses on the experiences of Peggy Lange, BA, RRT (RT Department Director, St. Cloud Hospital in St. Cloud, MN).

Over a three month period, St. Cloud Hospital ran a pilot program to test the effectiveness of continuous capnography monitoring Center for Surgical Care, PACU, surgical care units, interventional radiology, electrophysiology lab, and emergency trauma center.  The trial was successful, proving the monitors gave an early alert to the signs of respiratory distress, as well as resolving issues caused by nuisance alarms – particularly with patients experiencing sleep apnea or periods of hyperventilation.  As a result, continuous capnography monitoring was implemented hospital-wide. Read More

Must Reads

Patient Safety Weekly Must Reads (December 17, 2016)

This week in #patientsafety, we remember Leah Coufal, an 11-year-old girl who died after experiencing respiratory depression when she received fentanyl following a successful surgery. We also share an infographic showing the U.S. opioid epidemic by the numbers. From around the web, a study finds that clinician performance is the same when the volume of alarms is turned down, an article calls on pharmacists to lead efforts against the opioid epidemic, and an investigative piece calls attention to one company’s shady sales strategy.

Stay warm and happy reading!


Opioid Deaths Are (Still) Preventable: Remembering Leah. Leah Coufal died after experiencing opioid-related respiratory depression. We remember Leah on her death anniversary.

The U.S. Opioid Epidemic In Numbers. The PPAHS conducted a survey to gauge how clinicians and the public felt about the Surgeon General’s recommendations to fight the opioid epidemic. Advance for Nurses published an infographic summarizing our early findings.

From Around the Web:

Is It Safe to Turn Down the Volume of Hospital Alarms? New Study Chimes In: ‘Yes’. We wonder whether quieter alarms would have an impact on alarm fatigue.

ASHP Midyear: Pharmacists Can Take Lead on Addressing Opioid Crisis. Our survey found that most clinicians felt doctors should take the lead on addressing the opioid crisis. Perhaps pharmacists could lead it too?

Company gave doctor ‘one of the best nights of his life’ to boost fentanyl sales. Six former executives and sales representatives of one company were arrested following an indictment with allegations of bribery and kickbacks.

Opioid Safety, Patient Stories, Respiratory Compromise

Opioid Deaths Are (Still) Preventable: Remembering Leah


Leah walked into a Los Angeles hospital a healthy, 11-year old girl.  She needed an elective surgery to repair a condition called pectus carinatum.  Despite delays, the surgery went well, but Leah was in considerable pain; to manage it, she was given escalating doses of fentanyl, along with Ativan.  

Her mother, Lenore Alexander, was concerned by Leah’s increasing unresponsiveness – but was assured by staff that Leah would be ready to walk out of the hospital in the morning.  Exhausted, Lenore took a nap by her daughter’s bedside; it would be the last time Leah was seen alive.  Lenore woke to find Leah dead in bed.

In 2012, Lenore wrote an article for PPAHS asking if continuous monitoring would have saved her daughter, Leah.  The answer, then, was a resounding “yes”.  During her hospital stay, Leah received only infrequent spot checks from staff to confirm her condition despite the administration of powerful opioids.  If only she were monitored with capnography and pulse oximetry – we would not have another tragic story to tell.

Now, on the 14th anniversary of Leah’s death, we ask the same question: would continous monitoring have saved Leah’s life?   Read More

Must Reads, Patient Safety

Top 10 Patient Safety Must Reads – November 2016

We’re saying “hello” to December, and looking back at some of PPAHS’ top posts and tweets in November.

Top Posts

This month, as part of our new campaign targeting VTE in orthopedic patients, PPAHS was invited to become a partner of World Thrombosis Day!  We also provided bittersweet coverage regarding opioid safety, including celebrating St. Joseph’s/Candler Health System’s (SJ/C) 12-years event-free and opioid safety’s place – once again – on ECRI’s Top 10 Health Technology Hazards. Read More

Opioid Safety

The U.S. Opioid Epidemic In Numbers

opiod infographic thumbnailOpioid safety is one of the top patient safety concerns in the U.S.; with more than 2 million Americans dependent on opioids, opioid-related harm is an issue that has spans the continuum of clinical and public safety.

On August 25, 2016, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic. On the Surgeon General website, healthcare providers are encouraged to help solve the opioid epidemic.

The PPAHS conducted a survey to gauge how clinicians and the public felt about the Surgeon General’s recommendations to fight the opioid epidemic, with results released early November.  Key aspects of the survey were recently featured in an article published by Advance for Nurses.  The Advance Healthcare Network also distilled the survey’s top data points and recommendations. Read More