Alarm Fatigue, Opioid Safety

3 Limitations to the Use of Pulse Oximetry

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In PPAHS’ latest podcast, we spoke with Thomas W. Frederickson, MD, FACP, SFHM, MBA – lead author of the Society of Hospital Medicine RADEO guide (“Reducing Adverse Drug Events Related to Opioids”).  The RADEO guide is a comprehensive clinician manual created with the aim to decrease opioid-related adverse events in an inpatient setting. Read More

Alarm Fatigue

3 Questions to Ask About Post-Operative Care

by Mario Cattabiani (Director of Communications at Ross Feller Casey, LLP in Philadelphia)

Surgery can be a scary thing for any patient. Whether it is a minor procedure or life-saving necessity, all types of surgical procedures come with some degree of risk. To help ease your fears, it is a natural reaction to want to learn about everything that is going to happen during the procedure. You probably want to find out exactly what you need to do beforehand, what type of procedure is planned, who will be performing it, what the recovery will be like and when will you be able to go home. While all of these concerns and questions are completely valid, an important aspect of the process is left out.

Did you know that the first few hours after a surgical procedure are often just as risky as the actual operation? Just because you make it out of the operating room does not necessarily mean that you are in the clear just yet. While that can be a terrifying thought to come to grips with, it is the reality. Read More

Alarm Fatigue, Blood Clots, Must Reads

Are We Doing Enough to Prevent Patient Deaths? – Weekly Must Reads in Patient Safety (Feb 5, 2016)

Two patient deaths – one from alarm fatigue and one from a blood clot – make us stop and ask, “Are we doing enough to prevent patient deaths?

Death from Blood Clots

The Evening Post recently reported:

A teenage mother-to-be and her unborn baby were tragically killed by a DVT blood clot – just hours after finding out she was expecting a healthy boy.

Scarlett Holyoake, 18, was six months pregnant when she suddenly died from deep vein thrombosis after collapsing in her home.

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Alarm Fatigue, Must Reads

Hospitals Solving Alarm Fatigue – Weekly Must Reads in Patient Safety (Jan 15, 2016)

In a recent Wall Street Journal article, “At the Hospital, Better Responses to Those Beeping Alarms”, actions that hospitals are taking to help solve alarm fatigue are noted.

Hats off to @JackiOBrien1, @Nada44880470, @pfcryer, @BEastman_Sazan, @aimee_jungman, and many others for their tweets about alarm fatigue.

Here are key examples:

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Alarm Fatigue

Is Your Hospital Compliant with Joint Commission Requirements?

Will your hospital be compliant with The Joint Commission’s National Patient Safety Goal? In issuing this Goal, The Joint Commission stated:

In Phase II (beginning January 2016), hospitals will be expected to develop and implement specific components of policies and procedures. Education of those in the organization about alarm system management will also be required in January 2016.

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Alarm Fatigue, Blood Clots, Must Reads, Opioid Safety, Patient Safety, Practices & Tips, Respiratory Compromise

Top 5 Health and Safety Posts for 2015

The top 5 health and safety posts for 2015 on the Physician-Patient Alliance for Health & Safety (PPAHS) blog demonstrate risk management concerns for monitoring patients to prevent respiratory depression, preventing blood clots, and the need to manage device alarms.

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Alarm Fatigue, Patient Safety

How One Healthcare System Used Two Interventions to Tackle Alarm Fatigue

By Sean Power
November 11, 2015

How many telemetry alarms are generated in a single month by two hospitals, 716 beds, 36,386 admissions, 93,634 visits to the emergency department, 3,418 births, 453 open-heart surgeries, and 11,688 surgical procedures?

Over a quarter million, according to Kevin Smith, BSN, RN, CNML, CVRN-BC, Director II Cardiac Telemetry Services at NCH Healthcare System in Naples, Florida, in a presentation shared at the Association for the Advancement of Medical Instrumentation Foundation’s (AAMI) Patient Safety Seminar.
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Alarm Fatigue, Blood Clots, Hospital Acquired Conditions, Must Reads, Opioid Safety, Patient Safety, Patient Stories, Practices & Tips, Respiratory Compromise

Weekly Must-Reads in Patient Safety and Health Care (November 6, 2015) – When False Alarms Pollute Intensive Care

We have plenty of patient safety articles to share with you this week. From advice for nurses on how to educate patients about opioid diversion to tips for preventing medical errors in long-term care, audiences across the health care spectrum will benefit from some weekend reading.
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Alarm Fatigue, Respiratory Compromise

The Risk of Opioids in Post-Surgical Settings

This is the fourth article in a series exploring the impact of pulse oximetry alarm thresholds in hospitalized patients.

By J. Paul Curry, MD (anesthesiologist)

In the first article, “Improving the Safety of Post-Surgical Care,” I introduced the concept that, although the current approach to physiologic threshold monitoring (triggering an alarm when oxygen saturation falls below 90%) works well in the OR, it is unreliable on post-surgical floors. Read More