Must Reads

Patient Safety Weekly Must Reads (March 25, 2017)

This week in #patientsafety, we highlight again that it is Blood Clot Awareness Month. From around the web, three studies: one on the effect of hospital inspectors on patient safety; one on sepsis; and, one on the relationship between opioid supply levels and long-term use.

From PPAHS:

March is Blood Clot Awareness Month. Blood Clot Awareness Month is a time for us to highlight stories and resources that you can share with colleagues, patients, and loved ones to bring attention to blood clots.

From Around the Web:

When Hospital Inspectors Are Watching, Fewer Patients Die. A study published in JAMA Internal Medicine studied records of Medicare admissions from 2008 to 2012 at 1,984 hospitals and found that in the non-inspection weeks, the average 30-day death rate was 7.21 percent. But during inspections, the rate fell to 7.03 percent.

UAB study highlights risks of sepsis. A new study from researchers at the University of Alabama at Birmingham analyzing three different methods for characterizing sepsis has helped to illustrate the risk of death or severe illness attributable to the condition.

With a 10-day supply of opioids, 1 in 5 become long-term users. With an initial 10-day opioid prescription, about one-in-five patients become long-term users, according to data published Friday in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

Blood Clots

March is Blood Clot Awareness Month

Blood Clot Awareness Month logo

March is Blood Clot Awareness Month.

Spearheaded by the National Blood Clot Alliance, #BCAM is a time for patients, caregivers, healthcare professionals, and advocates to draw attention to deep vein thrombosis and venous thromboembolism.

According to the National Blood Clot Alliance:

“Blood clots do not discriminate. They can and do affect anyone from children to senior citizens, from professional athletes to mothers, women and men – no one is immune. Tragically, roughly 274 lives are lost each day in the U.S. simply because public awareness about life-threatening blood clots is so low.”

Blood Clot Awareness Month is a time for us to highlight stories and resources that you can share with colleagues, patients, and loved ones to bring attention to blood clots.

Blood Clots & Pregnant Women: A Doctor’s Perspective

The first resource we would like to share is a podcast interview with Peter Cherouny, M.D., Emeritus Professor, Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Chair and Lead Faculty: IHI Perinatal Improvement Community.

In this podcast, Dr. Cherouny outlines reasons why the maternal death rate is climbing and looks at the possible solutions.

Watch the podcast with Dr. Cherouny here.

Blood Clots & Pregnant Women: A Nurse’s Perspective

The second resource is a podcast interview with Colleen Lee MS, RN (Maternal/Perinatal Patient Safety Officer, Montefiore Medical Center).

Ms. Lee discusses the heightened risk of blood clots in pregnant women, and what can be done about it.

Watch the podcast with Ms. Lee here.

Free Resources: Blood Clot Safety Recommendations

PPAHS has assembled a team of patient safety experts to develop free clinical tools to help keep patients safe from developing blood clots.

We present two sets of concise recommendations that will help you reduce the risk of venous thromboembolism (VTE) in OB/GYN and stroke patients.

Download them here:

  1. OB VTE Safety Recommendations
  2. Stroke VTE Safety Recommendations
Must Reads

Patient Safety Weekly Must Reads (March 18, 2017)

This week in #patientsafety, we marked Patient Safety Awareness Week.

We want every week to be patient safety awareness week, so we published an article about saying so. We also shared a story written by a mother whose son died after a nursing error. From around the web, we highlight research on sepsis and opioid prescribing practices. We also direct you to an article from Canada looking at whether patients should feel comfortable taking opioids after surgery.

From PPAHS:

Patient Safety Awareness Week Needs to Be Every Week. We join others in calling on leaders to make every week patient safety awareness week at their healthcare facilities.

A Nursing Error Led to My Son’s Unexpected Death. This is the story of how the unmonitored use of patient-controlled analgesia and nursing errors led to the unexpected death of a mother’s only child (and how it might have been prevented).

From Around the Web:

Researchers Identify Biomarker that Predicts Death in Sepsis Patients. Duke scientists have discovered a biomarker of the runaway immune response to infection called sepsis that could improve early diagnosis, prognosis, and treatment to save lives.

Surgeons were told to stop prescribing so many painkillers. The results were remarkable. Despite the clickbait-y headline, this Washington Post article is legitimate and tells the story of how Dartmouth-Hitchcock Medical Center reduced the number of opioid pills they prescribed.

Should I be concerned about taking opioids after surgery?. For those in Canada, here’s a Globe and Mail article asking whether patients should be afraid to take opioids after surgery. The comments are worth reading; and share your opinion if you feel it appropriate to do so.

Patient Safety, Patient Stories

A Nursing Error Led to My Son’s Unexpected Death

This is the story of how the unmonitored use of patient-controlled analgesia and nursing errors led to the unexpected death of a mother’s only child (and how it might have been prevented).

By Victoria Ireland

On Saturday, the 5th of November, 2011, my life fell apart when my only son Tyler left this world.

One week before that, on the morning of the 28th of October, I received a phone call that no mother ever wants to receive. I was asked to go immediately to the hospital. And when I arrived, I was told that Tyler was found unresponsive and had suffered two cardiac arrests. I never got to speak to Tyler again.

Those days will forever be etched in my memory. While my heart will always ache from the loss of Tyler, I am telling his story in the hope that it will help prevent similar tragedies and that no parent will have to endure the pain of losing their child to nursing errors and unmonitored use of patient-controlled analgesia (PCA) pumps.

Read the full story on The Doctor Weighs In here.

Patient Safety

Patient Safety Awareness Week Needs to Be Every Week

By Sean Power

“Competent and thoughtful leaders contribute to improvements in safety and organizational culture.”

The Joint Commission, Sentinel Event Alert 57

Earlier this month, The Joint Commission released Sentinel Event Alert 57, The essential role of leadership in developing a safety culture, calling on leaders to prioritize and increase the visibility of everyday actions that create a culture of safety.

There is no better time to amplify that message than Patient Safety Awareness Week, March 12-18, and we are calling on leaders to make every week patient safety awareness week at their healthcare facilities. Read More

Must Reads

Patient Safety Weekly Must Reads (March 11, 2017)

This week in #patientsafety, we shared an article by Bradley Truax, MD, on pediatric sedation. We also shared a first-hand story written by the daughter of a patient who almost died of sepsis. From around the web, PIPSQC shared clinical videos on pediatric safety and a QI team implemented a very successful intervention for patients undergoing elective surgery.

Also, it’s Blood Clot Awareness Month! Tell us what your team is doing to improve blood clot safety.

From PPAHS:

Patient Safety Tip of the Week: Guideline Update for Pediatric Sedation. Continuing our efforts to bring in multiple #patientsafety perspectives, we have reposted an article on pediatric sedation safety (with permission).

I am running 50 miles for Sepsis, because more needs to be done. The daughter of a man who almost died from sepsis tells her story in this heartfelt first-hand account.

From Around the Web:

Children’s Hospitals’ Solutions for Patient Safety (SPS) – Prevention Bundle Videos. On the topic of pediatric safety, the Paediatric International Patient Safety and Quality Collaborative (PIPSQC) shared some great videos on pediatric safety in a clinical setting.

Impact of a peri-operative quality improvement programme on postoperative pulmonary complications. A quality improvement team cut postoperative pulmonary complications in half with a perioperative intervention.

Blood Clot Awareness Month 2017: “Know More, Share More”. March is Blood Clot Awareness Month. Share what your team is doing to improve blood clot safety.

Hospital Acquired Conditions, Patient Stories

I am running 50 miles for Sepsis, because more needs to be done

Editor’s Note: We came across a story by Jayne Bissmire, a woman running to raise funds for the UK Sepsis Trust. We were moved by how Jayne tells her story of how sepsis–a life-threatening condition that happens when the body’s response to an infection injures its own tissues and organs–has impacted her life by nearly taking her father from her.

We know now from research that sepsis accounts for more 30-day readmissions and is more costly than heart attacks, heart failure, chronic obstructive pulmonary disease and pneumonia. Behind these numbers-driven research papers, though, are the people whose lives are impacted by the condition.

Here is a first-hand account from one such person. Thank you, Jayne, for sharing your story and that of your father with our community of supporters.

My Sepsis Story

by Jayne Bissmire

I am running 50 miles for Sepsis, because more needs to be done. Read More

Opioid Safety, Practices & Tips

Patient Safety Tip of the Week: Guideline Update for Pediatric Sedation

This article was first published in Patient Safety Solutions in August 2016. As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted this with permission.

By Bradley T. Truax, MD

Our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” noted numerous cases of death related to sedation in dental practices. The majority of those cases occurred in pediatric patients. Read More

Must Reads

Patient Safety Weekly Must Reads (March 4, 2017)

This week in #patientsafety, we shared an article on opioids in dentistry by Bradley Truax, MD. Outpatient Surgery covered our position statement on patient ambulation. From around the web, NPR wrote about dentists working to use fewer opioids, a hospital reduced nuisance alarms by 30%, and The Joint Commission issued a new Sentinel Event Alert on developing a culture of safety.

From PPAHS:

Patient Safety Tip of the Week: Dental Patient Safety. As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted an article on dental patient safety (with permission).

Push to Make Ambulation a Key Patient Recovery Metric. Outpatient Surgery covered our position statement on patient ambulation.

From Around the Web:

Dentists Work To Ease Patients’ Pain With Fewer Opioids. Dr. Joel Funari performs some 300 tooth extractions annually at his private practice in Devon, Pa. He’s part of a group of dentists reassessing opioid prescribing guidelines in the state.

Hospital’s program reduces nuisance alarms 30 percent. Nurses at Palomar Health in California were part of a study designed to reduce alarm fatigue. The health system decreased its alarms by nearly 30 percent.

Sentinel Event Alert 57: The essential role of leadership in developing a safety culture. “Competent and thoughtful leaders contribute to improvements in safety and organizational culture,” says The Joint Commission.

Opioid Safety, Practices & Tips

Patient Safety Tip of the Week: Dental Patient Safety

This article was first published in Patient Safety Solutions on March 15, 2016. As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted this with permission.

By Bradley T. Truax, MD

We were recently asked why we haven’t done any columns on dental patient safety. While over the years we’ve encountered a few minor safety issues in dental cases in hospitals, we’ve never looked at the broader issue of safety in dental practice where it is usually practiced – outside the hospital.

So here goes! Read More