In the case of hospital care, the stakes are high, with errors potentially resulting in serious adverse events or even death. In the field of obstetrics & gynecology, these incidences can have a deeply personal impact, affecting the lives of mother, baby, family, and attending clinicians. It’s not surprising, then, that in the most catastrophic cases, the costs of obstetric malpractice suits can be astronomical.Read More →
Mr. Welch is a Clinical Engineer with 17 yrs experience in hospitals and over 24 yrs as an executive in the medical device industry. His focus has been on applying technologies to improve patient safety through continuous surveillance monitoring. Mr. Welch has ten patents and articles in the field of wireless physiologic monitoring, surveillance systems and alarm management. He regularly contributes to the AAMI Foundation on alarm safety and is a voting member on a number of International Standards committees.
Early detection of physiologic deterioration is essential in improving patient safety in acute care hospital settings. Patients in non-ICU settings who are recovering from surgery or special procedures are especially vulnerable because of private or semi-private room settings prevents direct observation and nurse to patient ratios are often 1:6. Experts in Rapid Response Systems (RRS) have arrived at a consensus that strengthening early detection through continuous monitoring is essential in improving the effectiveness of RRS but only if such systems do not impose a burden on the clinical staff. The high incidence of nuisance alarms and cost are two of the major barriers preventing broader adoption of continuous monitoring on the general care floor.Read More →
Can “perfect care” exist in the clinical setting? This is one of the questions that was asked at a recent conference that I spoke at with Bruce Pastner, MD, JD (Vice-Chair, Patient Safety & Quality, Inova Fairfax Women’s Hospital).
It’s a utopic vision for patient safety that we all strive for. But the unfortunate reality of healthcare today is that bad outcomes can happen; this is sadly true in practices regarded as higher-risk, such as obstetrics. Not all terrible events leading to death or major injury are predictable, preventable, or even treatable. What clinicians can do, however, is to focus on identifying the most preventable incidents and prepare for them.Read More →
Written by Lynn Razzano RN, MSN, ONC-C (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety).
When preventable medical errors occur, one of the very first questions asked by patients, families, the legal system, the press, and the public is: “were appropriate care standards met?”. As a professional Registered Nurse, I look at this question from a quality and patient safety perspective to ask what could have been done differently? What are the best practice medical standards, and why are they not applied across the US health care systems? How applicable should the medical standard of care be? And how do we, as clinicians and patient advocates, define the best practice standard of care?
The reality is that the definition of best practice and standard of care differs between acute care hospital settings and outpatient surgery centers. And, even then, the standard of care being applied by the ambulatory surgical center, anesthesiologist and the gastroenterologist may not be the same. Read More →
The Physician-Patient Alliance for Health & Safety (PPAHS) has released a YouTube video which discusses in nine minutes how to improve opioid safety. The video features highlights from over 10 hours of in-depth interviews released by PPAHS in 2016; altogether, the podcast series has generated over 130,000 cumulative views on YouTube. The podcast series brings together physicians, nurses, and respiratory therapists discussing how they have improved opioid safety in their hospitals.
According to Michael Wong, JD, Founder and Executive Director of PPAHS:
“In just nine minutes, the video summarizes experiences of clinicians in improving opioid safety in their hospital or healthcare facility, and reminds us of the tragic consequences of adverse events and deaths that may ensue if clinicians and healthcare executives are not proactive in promoting safety. We hope that the video will energize quality improvement and patient safety teams to strive to reduce adverse events and deaths related to opioid use.”
The opioid epidemic was one of the most heavily-covered, and hotly-debated, topic in patient safety covered in 2016. This dialogue has been mostly centered around the effects of ‘street’ use and abuse of prescription painkillers. In contrast, the PPAHS podcast series aims to highlight the preventable harm of opioid-induced respiratory depression during hospital procedures.Read More →
Editor’s Note: We came across a story by Jayne Bissmire, a woman running to raise funds for the UK Sepsis Trust. We were moved by how Jayne tells her story of how sepsis–a life-threatening condition that happens when the body’s response to an infection injures its own tissues and organs–has impacted her life by nearly taking her father from her.
We know now from research that sepsis accounts for more 30-day readmissions and is more costly than heart attacks, heart failure, chronic obstructive pulmonary disease and pneumonia. Behind these numbers-driven research papers, though, are the people whose lives are impacted by the condition.
Here is a first-hand account from one such person. Thank you, Jayne, for sharing your story and that of your father with our community of supporters.
My Sepsis Story
by Jayne Bissmire
I am running 50 miles for Sepsis, because more needs to be done. Read More →
The following is an excerpt of an article on bundled payments for joint replacement 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.
We’re bringing back a weekly review of the trending topics in patient safety from PPAHS and around the world. In this week, we highlight 2 guest contributors to PPAHS, the latest in opioid monitoring technology, and developments to the culture of patient safety. Read More →
The Press Gainey report found that hospitals with better nurse staffing and work environments tend to have fewer readmissions for heart failure, pneumonia and myocardial infarction. Says the Press Gainey report: