Opioid Safety, Patient Safety

Overriding Technology May Impact Patient Safety

Recent research by the Pennsylvania Patient Safety Authority has concluded that overrides of medical technology may impact the safety of patients.

The PA Authority analyzed 583 events reported during the period January 2013 to December 2014. Key findings from this analysis:

  • The majority (77%) were related to automated dispensing cabinets.
  • The most common classes of medications involved antibiotics (12.0%), opioids (12.0%), anticoagulants (7.4%), and high alert medications (26.4%).

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Opioid Safety, Respiratory Compromise

Reducing Errors by More than 60 Percent: PPAHS Presents at the Northern Regional Respiratory Care Conference

by Sean Power

Last week, the Physician-Patient Alliance for Health & Safety presented two cases in which health care facilities reduced PCA-related adverse drug events with continuous electronic monitoring.

Experts estimate that anywhere from 600,000 to 2,000,000 PCA errors occur each year. As Dr. Richard Dutton, Executive Director of the Anesthesia Quality Institute, states, “PCA errors certainly occur, both in programming and in delivery, but any published estimate is likely to be only the tip of the iceberg.” Read More

Opioid Safety, Respiratory Compromise

Third Leading Cause of Death is Preventable

Dr. Peter Pronovost (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) recently appeared on the Katie Couric Show on “Shocking Medical Mistakes”.

On the Show, Dr. Pronovost discussed the number of preventable deaths that occur each year in the United States: Read More

Alarm Fatigue, Opioid Safety, Respiratory Compromise

10 Reminders to Ensure Safer Use of Patient-Controlled Analgesia

PCA-related device events are three times as likely to result in injury or death. As Tim Ritter (Senior Patient Safety Analyst, Pennsylvania Patient Safety Authority) reminds us, “Over the six-year period from June 2004 to May 2010, data collected by Pennsylvania Patient Safety Authority revealed that there were approximately 4,500 reports associated with PCA pumps. Moreover, U.S. Food and Drug Administration’s (FDA) Manufacturer and User Device Experience (MAUDE) database demonstrates that PCA-related device events are three times as likely to result in injury or death as reports of device events involving general-purpose infusion pumps.” Read More

Opioid Safety, Respiratory Compromise

Monitoring Technology for PCA Pumps Can Prevent Adverse Events with Patient-Controlled Analgesia (PCA): So Why Are Hospitals Not Using It?

By Michael Wong

(This article has also been published in SurgiStrategies, which can be read here.)

According to its newly-updated, “How-to Guide: Prevent Harm from High-Alert Medication”, the Institute for Healthcare Improvement (IHI) looked at high-alert medications, which are “more likely than other medications to be associated with harm”.

One of the areas that the IHI singles out is narcotics. Read More

Opioid Safety, Respiratory Compromise

Reducing Errors With Patient-Controlled Analgesia Pumps: Q&A With Bryanne Patail of the National Center for Patient Safety

In this interview, Bryanne Patail, biomedical engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety, discusses patient-controlled analgesia (PCA) pumps and what the Veterans Health Administration has done to reduce errors and improve patient safety.

by Michael Wong

Bryanne Patail, biomedical engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety, discusses patient-controlled analgesia (PCA) pumps and what the Veterans Health Administration has done to reduce errors and improve patient safety. This interview was conducted with Michael Wong of the Physician-Patient Alliance for Health & Safety. Read More