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

Patient Safety

Pressure Ulcer Prevention Tools Presented At ASHRM Conference

At a recent meeting of the New Jersey chapter of the American Society for Healthcare Risk Management (ASHRM), health experts presented on how to prevent readmissions for pressure ulcers.

Pressure ulcers are a common hospital-acquired condition with far-reaching implications for patient safety.  It is estimated that 2.5 million patients are affected by pressure ulcers annually in the U.S.; about 60,000 patients will die nationwide directly from pressure ulcers.  The condition is extremely painful, costly (up to $11 billion each year in the U.S. alone), and largely preventable. Read More

Must Reads

Patient Safety Weekly Must Reads (December 2, 2016)

This week in #patientsafety, we look at the fact that opioid safety has yet again made the list of the ECRI Institute’s Top 10 Technology Hazards and we look at some key aspects of St. Joseph/Candler’s success in its continuous electronic monitoring program. From around the web, we share a video explaining how opioids cause harm and how their overprescription leads to drugs piling up in cupboards at home. We also share a story of a mother who died from blood clots – the coroner says her death was preventable.


Opioid Safety is again an ECRI Top-10 Health Technology Hazards for 2017. This is bittersweet. Bitter, because this problem is a major epidemic that has been going on for too long; sweet, because at least the topic is getting the attention it deserves.

Preventing Opioid-Related Adverse Events with Capnography. Continuous electronic monitoring has helped reduce serious adverse events related to opioid-induced respiratory depression at St. Joseph/Candler.

From Around the Web:

How the powerful opioid fentanyl kills. A video from the CBC explains how opioids work, and how they cause harm. Great for explaining the opioid epidemic to a lay audience.

Unused Opioids Pile Up in Medicine Cabinets, While Overprescribing Contributes to National Epidemic. Researchers at Johns Hopkins University School of Medicine, Baltimore, have found that health care providers dispense far more medicine than is necessary to treat pain after pediatric outpatient surgery.

Mum who died of blood clots two weeks after giving birth could have been saved, finds coroner. Marie Tompkins died from a blood clot. The coroner says the doctor failed to refer her to a scan that could have detected it.

Opioid Safety, Respiratory Compromise

Preventing Opioid-Related Adverse Events with Capnography

Patient Monitoring

This year, St. Joseph’s/Candler Health System (SJ/C) celebrated 12 years free from opioid-related adverse events.  The PPAHS had the pleasure of interviewing Harold Oglesby, RRT, Manager to uncover the SJ/C team’s learnings in implementing the quality improvement project.

From the inception of the project, continuous electronic monitoring with capnography has been a cornerstone technology to keeping patients at SJ/C safe.  Mr. Oglesby and his team implemented a continuous monitoring program with capnography after identifying a need for reliable, early indication of patient decline in ventilation.  Since the initial pilot, the monitors have shown tangible results:

“There was a couple of ‘aha’ moments when we saw that capnography giving us, sometimes an hour earlier, [indication] of a patient that was getting into distress.”

Effective implementation is crucial whenever new technology is introduced in a clinical setting.  During our interview, Mr. Oglesby speaks to three key learnings to make continuous monitoring with capnography a success. Read More

Patient Safety

Opioid Safety is again an ECRI Top-10 Health Technology Hazards for 2017

By Sean Power

The ECRI Institute released its annual list of top-10 health technology hazards. These hazards have major patient safety implications and should be top-of-mind for all clinicians and hospitalists who use health technology.

ECRI Institute 2017 Top-10 Health Technology Hazards report cover

According to the authors of the report:

“Patients receiving opioids—such as morphine, hydromorphone, or fentanyl—are at risk for drug-induced respiratory depression. If not detected, this condition can quickly lead to anoxic brain injury or death. Thus, spot checks every few hours of a patient’s oxygenation and ventilation are inadequate.

“ECRI Institute recommends that healthcare facilities implement measures to continuously monitor the adequacy of ventilation of these patients and has recently tested and rated monitoring devices for this application.”

Last year, we interviewed Stephanie Uses, PharmD, MJ, JD, Patient Safety Analyst at ECRI Institute, to look at how hospitals and other healthcare facilities can prevent harm and death to patients with improved opioid safety. It is still relevant today.

Here is the interview in full.

You can also read the transcript here.

Must Reads

Patient Safety Weekly Must Reads (November 25, 2016)

This week in #patientsafety, we shine the spotlight on respiratory therapists for all the work they do in keeping patients safe. We also look at whether bundled payments for hip and knee replacements are potentially risky when it comes to safe care. From around the web, we feature a great article highlighting stories of patients found “dead in bed”, possibly from providing too much pain medication (long-time PPAHS supporters will be familiar with most of these stories). Read More

Opioid Safety, Respiratory Compromise

Respiratory Therapists Are Integral to Reducing Opioid-Related Adverse Events

Harold Oglesby - Celebrating 10 Years's Event Free

In a recent interview with Harold Oglesby, RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJ/C), our discussion focused on the success factors that contributed to SJ/C’s 12 years free from opioid-related adverse events.

During the interview, Mr. Oglesby highlighted five key learnings from his experiences in implementing and continuously improving SJ/C’s QI initiative.  One of these learnings was the importance of involving Respiratory Therapists (RT) throughout the process. Read More

Blood Clots, Hospital Acquired Conditions

Why Bundled Payments for Joint Replacement May Be Risky for Patients

The following is an excerpt of an article written by Michael Wong, JD, Executive Director of PPAHS and Lynn Razzano, RN, MSN, ONCC, Clinical Nurse Consultant at PPAHS.  It was first appeared on The Doctor Weighs In on November 18, 2016.  To read the full article, please click here.


According to the Centers for Medicare & Medicaid Services (CMS), hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries. In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations. CMS says that there is little consistency across providers in terms of the quality and cost of care for these procedures.

With an aim to improve the consistency of the quality and cost of care among providers,  CMS has introduced a new payment model, Comprehensive Care for Joint Replacement (CJR), in April 2016, using a concept known as bundled payments.

A significant aspect of this new model is that it contains exceptions to what will be reimbursed—exceptions that could prove potentially harmful to patients recovering from hip and knee replacements. Reconsidering these exceptions could go a long way in improving patient safety, reducing the number of readmissions, and reducing the cost of care for patients undergoing hip and knee replacement. Read More

Must Reads

Patient Safety Weekly Must Reads (November 18, 2016)

This week in #patientsafety, we shared our findings from our survey on responses to the Surgeon General’s letter on the opioid epidemic and put venous thromboembolism in the spotlight with a new partnership with World Thrombosis Day. From around the web, a mother penned an article about the tragic and preventable death of her son, Minnesota respiratory therapists are recognized for implementing a program to detect respiratory depression at St. Cloud Hospital in St. Cloud, MN, and the ECRI Institute released its top ten healthcare technology hazards of 2017 (undetected opioid-induced respiratory depression yet again makes the top five).


Physicians on Surgeon General’s Letter on Opioid Epidemic: Survey Results. In August, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic. We conducted a survey to gauge reactions to the Surgeon General’s appeal. Read More

Blood Clots, Patient Safety

Physician-Patient Alliance Partners with World Thrombosis Day

Good news!

The Physician-Patient Alliance for Health & Safety has been invited to become a partner of World Thrombosis Day, an international multi-organizational campaign devoted to increasing global awareness about thrombosis, including its causes, risk factors, signs/symptoms, evidence-based prevention and treatments.

World Thrombosis Day aims to highlight the need for action on thrombosis, specifically underscoring the unrecognized threat and serious consequences (morbidity and mortality) related to venous thromboembolism (VTE).

Know Thrombosis Hospital Associated Infographic
Read More