By Institute for Safe Medication Practices (ISMP)
Editor’s Note: This article first appeared on the ISMP website. It discusses the role that inadequate monitoring and muted alarms played in the recent tragic recent death of a 17-year old following a tonsillectomy. PPAHS has previously discussed deaths of pediatric patients following dental or oral procedures. We welcome your thoughts and comments on this issue.
Problem: Last April, a 17-year-old girl died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentaNYL in the postanesthesia care unit (PACU). The case made headline news again recently when a civil lawsuit filed by the teen’s parents was resolved. While it is too late to reverse the tragic outcome of this case, we call upon all hospitals and outpatient surgery centers to learn from the event and take action to prevent a similar tragedy in your facility. Read More
By Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)
Being able to easily assess a patient’s condition via a single, multi-parameter indicator would help clinicians determine whether changes in treatment are needed. The desire for such an indicator was confirmed in two surveys conducted by the Physician-Patient Alliance for Health & Safety (PPAHS) conducted in 2013 and again in 2015.
In PPAHS 2013 First National Survey of Patient-Controlled Analgesia Practices, 7 out of 10 hospitals indicated they would like “a single indicator that accurately incorporates key vital signs, such as pulse rate, SpO2, respiratory rate, and etCO2.” Respondents to this survey consisted of a mix of clinicians—18% physicians, 35% non-physicians (such as RTs and RNs), and 47% pharmacists.
A similar desire for a multi-parameter indicator was also found in a 2015 survey of nurses from the American Hospital Association. In this nursing survey, it was found that 67% of respondents said that they would like a single monitor multi-parameter device that measures all current physiological monitoring parameters. Read More
By Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety) and Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant , PPAHS)
ECRI Institute, in its report Top Ten Safety Concerns for 2016, again identified a lack of appropriate monitoring of patients receiving opioids as a major issue.
A lack of resources, especially money, is often cited by hospitals as a major obstacle to implementing continuous electronic monitoring. Read More
By Kenny Lin, MD, MPH
My patients lie to me every day. Some tell me that they have been taking their medications regularly when they haven’t. Some say that they have been eating a healthy diet and exercising for at least 30 minutes every day and don’t know where the extra pounds are coming from. Some lie that they are using condoms every time they have sex, that they have quit smoking, and if they drink alcohol at all, it’s only a single glass of wine with dinner. They bend the truth for many reasons: because they want to please their doctor, because they don’t like to admit lapses of willpower, or because they are embarrassed to tell me that they can’t afford to pay for their medications. I forgive them; it’s part of my job to understand that patients (and health professionals) are only human. The only lies that I find hard to forgive are the lies about pain. Read More
At the International Conference on Opioids (ICOO), which took place in Boston June 5-7, 2016, the Physician-Patient Alliance for Health & Safety (PPAHS) presented a poster on the survey of nurses it conducted. The survey’s objective was to identify:
- Practices and technologies that nurses believe are needed to reduce the occurrence of respiratory compromise and
- Those areas of medical practice that would benefit most from improved intervention.
Yesterday, at the International Conference on Opioids, the Physician-Patient Alliance for Health & Safety presented a poster on the nursing survey that we conducted with nurses at the American Hospital Association.
The survey’s objective was to:
- Practices and technologies that nurses believe are needed to reduce the occurrence of respiratory compromise.
- Areas of improvement in patient monitoring where nurses believe interventions can be implemeted.
Below are reactions from attendees to the PPAHS poster: Read More
ECRI Institute recently released the 2016 Top 10 Patient Safety Concerns for Healthcare Organizations.
In putting together this year’s list, ECRI synthesized data from a number of sources, as set forth in their Executive Brief:
- Routine review of events in the PSO [Patient Safety Organization] database, which contained more than 1.2 million events at the end of 2015,
- PSO members’ root-cause analyses and research requests,
- Topics reflected in HRC Alerts, and
- Voting by a panel of internal and external experts.
by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)
Congress has been busy trying to pass a slew of bills that may help reduce the prescription drug abuse and heroin epidemic.
To better understand why diversion, misuse, abuse, and overdose of opioids is a bipartisan issue that requires people from both sides of the aisle to come together, I interviewed Michael C. Barnes, Esq. (Executive Director, Center for Lawful Access and Abuse Deterrence). Read More
The recent Anesthesiology News article, “Modeling Shows Potential Cost Savings With Capnography Monitoring,” (2016;42:33-34) discusses research by Rhodri Saunders, DPhil, health economist at Ossian Health Economics and Communications in Basel, Switzerland. Dr. Saunders found that monitoring patients with capnography “reduced the proportion of patients experiencing greater than one adverse event (AE) by more than 27%.” Read More
In January 2016, the Association of periOperative Registered Nurses (AORN) released Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia.
As stated by AORN, the goal of moderate sedation is:
drug-induced, mild depression of consciousness achieved with the use of sedatives or a combination of sedatives and analgesic medications, most often administered intravenously, and titrated to achieve a desired effect … to reduce the patient’s anxiety and discomfort.
AORN in releasing this guideline warns that the “patient may slip into a deeper level of sedation than intended; therefore, practitioners who administer moderate sedation/analgesia should be able to rescue a patient who enters deep sedation/analgesia.”
There are three keys to AORN’s Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia: Read More