Patient Safety

Are These Healthcare Decisions Reasonable or Do They put Patients At-Risk? Articles PPAHS has been reading the week of February 19, 2018

Articles we have been reading this past week of February 19, 2018 made us ask ourselves whether recent healthcare decisions are reasonable. What do you think?

Why do patient monitoring guidelines of the American Society for Gastrointestinal Endoscopy differ from those of the American Society of Anesthesiologists?

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Alarm Fatigue

Maria Cvach’s 6 Steps for Improving Alarm Management The Experience of John Hopkins Hospital in Reducing Alarm Fatigue

Maria Cvach, DNP, RN, FAAN, who is director of policy management and integration for Johns Hopkins Health System, recently spoke with the Physician-Patient Alliance for Health & Safety (PPAHS) about the experience of John Hopkins Hospital in improving patient safety and reducing alarm fatigue.

Clinical Education Podcast Features Maria Cvach on Reducing Alarm Fatigue

Maria Cvach

In a clinical education podcast that was released on PPAHS’s YouTube Channel, Ms. Cvach discussed how John Hopkins Hospital was ahead of the curve in managing alarm fatigue, which became The Joint Commission proclaimed as a national patient safety goal in 2014. Johns Hopkins Hospital had formed an alarm management committee in 2006:

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Patient Safety

How to Keep Patients Safe From Harmful Prescription Drug Side Effects

In this article, Cal Cook (Consumer Finance Investigator, ConsumerSafety.Org) cautions patients about the prescription drug side effects, and particularly “black box” warnings. It’s up to the doctor’s discretion to determine whether the benefits outweigh the side effects for the patient’s individual situation.

By Cal Cook (Consumer Finance Investigator, ConsumerSafety.Org) investigates and writes about consumer-focused topics including finance, scams and safety. His passion lies in exposing fraud across all industries to protect consumers.

A “black box” warning is a boxed warning on a prescription drug label that indicates the drug can have seriously harmful side effects. This is the most severe type of warning by the Food and Drug Administration (FDA). According to prescription drug retailer Walgreen’s, this warning is only used “when there is reasonable evidence of an association of a serious hazard with the drug.” There are certainly instances when it’s helpful to give such drugs to patients, but it’s up to the doctor’s discretion to determine whether the benefits outweigh the side effects for the patient’s individual situation.

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Must Reads

5 Suggestions for Improving the Health of Babies Articles PPAHS has been reading the week of February 12, 2018

Articles we have been reading this past week of February 12, 2018 provide 5 suggestions for improving the health of babies.

#1 – Exercise the Appropriate Standards of Care

PPAHS has been following the case of Amber Athwal, who suffered brain damage after undergoing dental surgery to extract some of her teeth.

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Opioid Safety, Respiratory Compromise

Columbia University Medical Center Webinar on Respiratory Compromise Prevention, Recognition and Intervention Clinicians at Columbia University Medical Center offer Their Recommendations for Safer Patient Care

The Physician-Patient Alliance for Health & Safety (PPAHS) is pleased to announce that the Columbia University Medical Center (CUMC) webinar on respiratory compromise prevention, recognition and intervention is now available on the PPAHS YouTube Channel.

Columbia University Medical Center Webinar on Respiratory Compromise Prevention, Recognition and Intervention

Columbia University Medical Center Webinar on Respiratory Compromise Prevention, Recognition and Intervention

The webinar features the following clinicians from CUMC:

  • Paul Boerem, ACNP, RT, Critical Care Nurse Practitioner and Certified Respiratory Therapist, Department of Medicine, Pulmonary, Allergy and Critical Care;
  • Monica P. Goldklang, MD, Assistant Professor of Medicine (in Anesthesiology)
    Department of Anesthesiology, Critical Care Medicine;
  • Steven E. Miller, MD, Assistant Professor of Anesthesiology (Moderator)
    Department of Anesthesiology, Critical Care Medicine; and
  • Amanda J. Powers, MD, Assistant Professor of Surgery (in Anesthesiology)
    Department of Surgery, Acute Care

The Respiratory Compromise Institute (RCI) — a diverse coalition of 13 medical and safety organizations devoted to raising awareness about the condition — defines respiratory compromise as a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

Is Respiratory Compromise the New Sepsis?

“This webinar highlights how respiratory compromise is a serious, potentially deadly patient safety issue that may be avoidable when proper prevention and identification strategies are used, and when healthcare providers are equipped with comprehensive patient monitoring technology,” explains Michael Wong, JD, Executive Director, PPAHS. “Education about the condition and how it can be prevented is vital to reducing its incidence. We encourage all clinicians to view the webinar to learn how they can provide the safest possible care for their patients, particularly those with risk factors that may increase their chances of developing respiratory compromise.”

Risk factors for respiratory compromise include obstructive sleep apnea, older age, obesity and chronic obstructive pulmonary disease1-2, in addition to receiving opioid administration.3

The webinar was made possible through an educational grant from Medtronic plc, one of the world’s largest medical technology, services and solutions companies.

REFERENCES

  1. Frederickson TW, Gordon DB, De Pinto M, et al. Reducing Adverse Drug Events Related to Opioids Implementation Guide. Philadelphia: Society of Hospital Medicine, 2015.
  2. Karcz M, Papadakos PJ. Respiratory complications in the postanesthesia care unit: A review of pathophysiological mechanisms. Can J Respir Ther. 2013;49(4):21-29.
  3. Jarzyna D, Jungquist CR, Pasero C, et al. American society for pain management nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118-145. doi: 10.1016/j.pmn.2011.06.008.
Patient Safety

Preventing medical errors during a transfer of care

A transfer of care can result in a medical error. In this joint article between the Canadian Patient Safety Institute and the Physician-Patient Alliance for Health & Safety, Michael Wong, JD (Founder & Executive Director of the Physician-Patient Alliance for Health & Safety) and Stephen Routledge, MPH (Patient Safety Improvement Lead, Canadian Patient Safety Institute) discuss how medical errors during transfers of care can be prevented.

In particular, two key resources are referred to in the article.

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Alarm Fatigue

ECRI’s Advice on Alarm Management Ensure proper settings of secondary notifications

ECRI Institute’s Marc Schlessinger, RRT, MBA, FACHE, who is senior associate at their applied solutions group, recently spoke with the Physician-Patient Alliance for Health & Safety (PPAHS) on how to improve alarm management. The interview can be heard on the clinical education podcast, “Improving Patient Safety and Reducing Alarm Fatigue: The Right and Wrong Way to Use Continuous Surveillance Monitoring.”

Michael Wong, JD (Founder/Executive Director, PPAHS) noted the work that ECRI has done to help improve patient safety and reduce alarm fatigue citing ECRI’s recent “Top 10 Health Technology Hazards for 2018:”

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Patient Safety

5 Troubling Healthcare Facts Articles PPAHS has been reading the week of January 22, 2018

The articles we have been reading this past week of January 22, 2018 discuss 5 troubling healthcare facts.

#1 Troubling Healthcare Fact – Not enough experienced nurses

Shawn Kennedy, MA, RN asks a very good question in the title of her article, “Experienced Bedside Nurses: An Endangered Species?”:

“The trend toward our hospitals being primarily populated with nurses with less than two years’ experience is worrisome.”

We don't have enough experienced #nurses #patientsafety Click To Tweet

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Alarm Fatigue

Improving Patient Safety and Reducing Alarm Fatigue The Right and Wrong Way to Use Continuous Surveillance Monitoring

The Physician-Physician Alliance for Health Safety released a clinical education podcast on improving patient safety and reducing alarm fatigue.

Discussing the right and wrong ways to use continuous surveillance monitoring are a  distinguished panel of experts:

  • Leah Baron, MD is chief of the department of Anesthesiology at Virtua Memorial Hospital;
  • Maria Cvach, DNP, RN, FAAN  is director of policy management and integration for Johns Hopkins Health System; and
  • Marc Schlessinger, RRT, MBA, FACHE is senior associate at ECRI Institute’s applied solutions group.

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