Alarm Fatigue

ECRI’s Top Ten Technology Hazards for 2018 Middleware Technology Must be Configured Appropriately to Reduce Alarm Fatigue

Recently, ECRI Institute released its Top Ten Technology Hazards for 2018. The purpose behind ECRI’s yearly list is to promote the safer use of technology:

The safe use of health technology—from beds and stretchers to large, complex imaging systems—requires identifying possible sources of danger or difficulty with those technologies and taking steps to minimize the likelihood that adverse events will occur. This list will help healthcare facilities do that.

Number 4 on this list deals with how Missed Alarms May Result from Inappropriately Configured Secondary Notification Devices and Systems:

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Patient Safety

CMS Proposes Measuring Opioid Related Adverse Respiratory Events Why Measure Some Opioid Related Adverse Events and Not Others?

Centers for Medicare & Medicaid Services (CMS) recently released its List of Measures under Consideration.

One of the measures under consideration is MUC17-210 which measures “Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events”:

“This measure will assess opioid related adverse respiratory events (ORARE) in the hospital setting. The goal for this measure is to assess the rate at which naloxone is given for opioid related adverse respiratory events that occur in the hospital setting, using a valid method that reliably allows comparison across hospitals.”

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Patient Safety

Three resources to prevent medical errors during transfer of care Joint Article by Canadian Patient Safety Institute and PPAHS

Co-authored by Stephen Routledge, MPH, Patient Safety Improvement Lead, Canadian Patient Safety Institute and Michael Wong, JD, Founder & Executive Director of the Physician-Patient Alliance for Health & Safety

Medical errors can be costly for both patient and hospital. As defined by the Joint Commission: In order to keep patients safe, clinicians should focus on the three key points along the patient’s continuum of care. To help, we offer these free resources:

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Patient Safety, Practices & Tips

Family Caregiving is Like Having a Full-Time Job Technological Solutions That May be Helpful

By John Schall, Chief Executive Officer of Caregiver Action Network (CaregiverAction.org)

Family caregiving can be like having a full-time job. Caregivers manage doctor appointments, provide transportation, make sure medications are taken on time, and keep the home going – to name just a few of the vital tasks that they perform on a daily basis. This can feel overwhelming. To do all this, caregivers sometimes need help. Fortunately, technology can make life a bit easier for family caregivers, and can help keep loved ones safe and healthy. What’s more, these services can help caregivers stay on top of it all and enable them to restore some balance to their lives.

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Blood Clots, Patient Safety

National Patient Safety Goal to Reduce the Patient Harm from Anticoagulants OB VTE and Stroke VTE Safety Recommendations now World Thrombosis Day Resources

Anticoagulants (more commonly referred to as blood thinners) are routinely used to treat, prevent and reduce the risk of venous thromboembolism (VTE), which consists of prevent deep vein thrombosis (DVT) and pulmonary embolism (PE).

According to World Thrombosis Day, 1 in 4 people worldwide are dying from conditions caused by thrombosis:

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Opioid Safety, Respiratory Compromise

Today’s Must-Have: Capnography Monitoring During Conscious Sedation Clinical Education Podcast with Drs. Matt Kurrek and Richard Merchant

Today, the Physician-Patient Alliance for Health Safety released a clinical education podcast with Matt Kurrek, MD, FRCPC (Professor, Department of Anesthesia, University of Toronto) and Richard Merchant, MD, FRCPC (Clinical Professor, University of British Columbia, Department of Anesthesia, Pharmacology & Therapeutics).

Drs. Kurrek and Merchant coauthored an editorial, “Yesterday’s Luxury, Today’s Necessity” after the Canadian Anesthesiologists’ Society [CSA] published its revised 2012 guidelines to the practice of anesthesia. The CSA guidelines recommend capnography monitoring during conscious sedation. In the podcast, Drs. Kurrek and Merchant discuss why capnography monitoring may have been considered yesterday’s luxury, but is now a necessity during conscious sedation.

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Opioid Safety, Respiratory Compromise

Capnography The Ventilation Vital Sign

Editor’s Note: This research was presented as a poster at the 2017 ANCC National Magnet Conference.

By Eric Griffin MSN, RN, CEN (Magnet Program Director, Baystate Medical Center) and Laura Bolella MSN, RN (Assistant Nurse Manager, Baystate Medical Center)

For over a hundred years nurses have monitored the same vital signs. Unfortunately these vital signs can be slow to change, inaccurate, and misleading. Although there have been modern advances in physiological monitoring devices, their acceptance has been limited. Pulse oximetry developed in the early 1970’s is extremely useful in measuring oxygenation, although it has limitations related to the following factors: poor signal strength, fingernail polish, anemia, patient motion, calloused skin, hypoperfusion, time lag, and vasoconstriction.

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Opioid Safety, Respiratory Compromise

Opioids Can Cause Adverse Events and Patient Deaths: ECRI Institute Patient Safety Organization’s Deep Dive Analysis Three Clinical Education Podcasts on Preventing Opioid-Related Harms

Despite the focus on appropriate use of opioids for pain management, ECRI Institute Patient Safety Organization (PSO) found that there are many hospitals that continue to experience opioid-related adverse events. To help prevent further patient harms and deaths, PSO conducted a deep dive analysis of adverse events related to opioids in the acute care setting.

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Opioid Safety, Respiratory Compromise

Standards for Dental Anesthesia Should Require Patient Monitoring An Update and Commentary on 5-Year Old Amber Athwal who Suffered Brain Damage Following Teeth Extraction

Five-year old Amber Athwal suffered brain damage after having dental surgery to extract some of her teeth. For our earlier post, which provides a summary of the lawsuit , “Capnography Monitoring of Five-Year Old Amber Athwal May Have Prevented Her Brain Damage,” please click here.

Dr. William Mather Tribunal Hearing

CBC News reports that Dr. William Mather, the dentist who performed the dental procedure which resulted in “permanent brain damage because of oxygen deprivation”, faces five counts of unprofessional conduct, and has pleaded guilty to three of the charges. Dr. Mather recently retired from dental practice.

Dr. Mather’s colleague, Dr. Darren Fee recently testified at the tribunal hearing investigating the Amber case:

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Opioid Safety, Respiratory Compromise

7 Must Reads for Beating the Opioid Epidemic Don't Just Talk, Do Something About this Problem

This week even the White House took notice of the opioid epidemic, declaring opioid abuse a national public health emergency. However, the opioid epidemic was recognized as early as the 1990s, when doctors became increasingly aware of the burdens of pain.

But, saying there is a problem – the opioid epidemic which has long been recognized – and doing something about it, are two completely different things.

To help do something about it, we offer 7 must reads for beating the opioid epidemic:

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