Must Reads, Patient Safety

8 Ways We Need to Reconsider How We Think About Patient Safety Articles PPAHS have been reading the week of April 16, 2018

Articles we have been reading this past week of April 16, 2018 ask us to reconsider how we think about patient safety.

#1 – COPD prevalence is nearly double in rural areas compared to metropolitan areas

The risk of COPD is nearly double in rural areas compared to that in urban areas, according to CDC’s Weekly Morbidity and Mortality Report.

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Blood Clots

PPAHS Participates in 1st Annual Anticoagulation Summit

Patient advocates and leading medical societies involved in awareness building and improving patient safety in Atrial Fibrillation (Afib) and venous thromboembolism (VTE) gathered recently for the 1st Annual Anticoagulation Summit, a two-day conference.

Michael Wong, JD, founder and Executive Director of the Physician-Patient Alliance for Health & Safety (PPAHS), presented a poster on the OB VTE Safety Recommendations, which were released by PPAHS, in collaboration with the Institute for Healthcare Improvement and the National Perinatal Association. The recommendations, compiled by a panel of health experts, give clinicians a step-by-step checklist to help assess all OB patients’ risks for VTE and identify the appropriate prophylaxis regimen to improve health outcomes for maternal patients. Read More

Must Reads

Patient Safety Weekly Must Reads (June 3, 2017) Tools to enhance patient safety

This week’s must reads focus on patient safety tools.

This week in #patientsafety, PPAHS announced our position that all patients receiving opioids must be monitored with capnography. From around the web, the American Journal of Nursing summarized venous thromboembolism (blood clots) guidelines from American College of Chest Physicians, Ontario released a dataset and tool to explore opioid-related morbidity and mortality, and Pain Medicine News discussed a researcher’s exploration of alternatives to opioids. Read More

Must Reads

Patient Safety Weekly Must Reads (March 25, 2017)

This week in #patientsafety, we highlight again that it is Blood Clot Awareness Month. From around the web, three studies: one on the effect of hospital inspectors on patient safety; one on sepsis; and, one on the relationship between opioid supply levels and long-term use.


March is Blood Clot Awareness Month. Blood Clot Awareness Month is a time for us to highlight stories and resources that you can share with colleagues, patients, and loved ones to bring attention to blood clots.

From Around the Web:

When Hospital Inspectors Are Watching, Fewer Patients Die. A study published in JAMA Internal Medicine studied records of Medicare admissions from 2008 to 2012 at 1,984 hospitals and found that in the non-inspection weeks, the average 30-day death rate was 7.21 percent. But during inspections, the rate fell to 7.03 percent.

UAB study highlights risks of sepsis. A new study from researchers at the University of Alabama at Birmingham analyzing three different methods for characterizing sepsis has helped to illustrate the risk of death or severe illness attributable to the condition.

With a 10-day supply of opioids, 1 in 5 become long-term users. With an initial 10-day opioid prescription, about one-in-five patients become long-term users, according to data published Friday in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

Patient Safety

Top 10 Articles of 2016

Happy Holidays!

We’d like to wish you a safe and healthy 2017.

As we prepare for 2017, we reflect back on the top 10 articles from 2016.

Opioid Safety

  1. Physicians on Surgeon General’s Letter on Opioid Epidemic: Survey Results. The Surgeon General issued an Open Letter on the Opioid Epidemic. We looked into how clinicians and other patient safety experts felt about it.
  2. The U.S. Opioid Epidemic In Numbers. Related, Advance for Nurses generated an infographic summarizing your responses.
  3. 12 Years of Event-Free Opioid Use. In 2016, St. Joseph’s/Candler Health System celebrated 12 years free from Serious Adverse Events related to Opioid-Induced Respiratory Depression since the implementation of its continuous monitoring program.

Alarm Safety

  1. 3 Ways to Make Opioids Safer. Peggy Lange, RT, Director of the Respiratory Care Department at St. Cloud Hospital, discussed the importance of setting alarm thresholds for each patient in this podcast.
  2. Drawn Curtains, Muted Alarms, And Diverted Attention Lead To Tragedy In The Postanesthesia Care Unit. Sadly, alarms on the monitoring equipment used to alert healthcare professionals to changes in the patient’s cardiac and respiratory status were muted in one tragic death of a 17-year-old.
  3. A New Tool to Predict Respiratory Failure: An Interview with Hiroshi Morimatsu, MD, Ph.D. Could this multi-parameter indicator help counter alarm fatigue?

Bloot Clots Safety

  1. New PPAHS Campaign Targeting Orthopedic Venous Thromboembolism. VTE is the third-most prevalent reason for readmission after surgery, and about 1 million hip and knee replacement surgeries happen each year in the U.S.
  2. Physician-Patient Alliance Partners with World Thrombosis Day. As part of our new campaign, we partnered with World Thrombosis Day in 2016. Looking forward to working together in 2017.
  3. Why Bundled Payments for Joint Replacement May Be Risky for Patients. We took a look at whether patients are receiving evidence-based or reimbursement-based care under the Bundled Payments model.

Special Mention

  1. Why All Medical Schools Must Incorporate Quality Improvement and Patient Safety into Their Curriculums. This position by Molly Siegel generated plenty of engagement on the Twittersphere and is a theme that cuts across all of our priority areas.
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.

Blood Clots

New PPAHS Campaign Targeting Orthopedic Venous Thromboembolism

PPAHS will be beginning a new #patientsafety campaign to develop practical solutions to help assess and prevent venous thromboembolism (VTE) in patients undergoing orthopedic procedures, particularly total knee and hip replacement.  More commonly known as blood clots, VTE consists of both deep vein thrombosis (DVT) and pulmonary embolisms (PE) . 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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Blood Clots, Must Reads, Opioid Safety, Patient Stories

How much safer are we? – Weekly Must Reads in Patient Safety (Jan 29, 2016)

In a recent article, Peter Pronovost, MD, PhD, FCCM (Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient; Member of the Physician-Patient Alliance for Health & Safety PCA Safety Panel and OB VTE Recommendations Working Group) asks a great question, “Patient Safety at 15: How Much Have We Grown?”.

Dr. Pronovost reflects on the past 15 years:

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