Alarm Fatigue, Blood Clots, Must Reads, Opioid Safety

Top 16 Patient Safety Must Reads of 2014

This year, the Physician-Patient Alliance for Health and Safety introduced a weekly round-up of must-read articles in patient safety. The hand-picked list has consistently seen high engagement from our dear readers.

With that in mind, we thought we would compile a list of the Top Patient Safety Must Reads of 2014. Read More

Alarm Fatigue, Must Reads, Respiratory Compromise

Weekly Must Reads in Patient Safety (Nov 28, 2014)

Happy Thanksgiving!

Do We Need to Start a Revolution? – This is the question asked by Fred N. Pelzman, MD, who writes:

Over and over again, we were told about the sorry state of the U.S. healthcare system, how we are first in cost and last in quality, and there’s something inherently wrong with the way “we” take care of people in this country.

Read More

Blood Clots

Preventing OB Death and Adverse Events from Blood Clots: Physician-Patient Alliance for Health & Safety to Present at ACOG Annual Conference

The Physician-Patient Alliance for Health & Safety (PPAHS) is pleased to announce that it will be hosting a lunch and learn session on the recently released OB VTE Safety Recommendations at the upcoming annual conference of the American Congress of Obstetricians and Gynecologists (ACOG). The ACOG annual meeting is being held in Chicago from April 26-30, 2014. Read More

Opioid Safety, Respiratory Compromise

Continuous Electronic Monitoring Reduces Adverse Events and Hospital Expenditures: Physician-Patient Alliance for Health & Safety Awarded Permanente Journal Service Quality Award

The Physician-Patient for Health & Safety (PPAHS) is pleased to announce that its presentation on the national survey of hospitals on patient-controlled analgesia (PCA) hospital practices was awarded the Permanente Journal Service Quality Award. The award was presented December 10, 2013 at The 25th Annual IHI National Forum on Quality Improvement in Health Care. Read More

Blood Clots

New VTE Safety Recommendations Prevent Blood Clots In Pregnant Mothers: Healthcare Organizations Encourage Use of Venous Thromboembolism Recommendations to Reduce Adverse Events and Save Lives

The Physician-Patient Alliance for Health & Safety, the Institute for Healthcare Improvement and the National Perinatal Association are pleased to announce the release of safety recommendations targeting the prevention of venous thromboembolism (VTE) in maternal patients. Read More

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

Update on CMS Proposed Quality Measure on PCA Patient Safety

We would like to thank all of those who submitted comments on the proposed quality measure being considered by CMS regarding the monitoring of patients using patient-controlled analgesia (PCA) pumps.

In the report submitted by the National Quality Forum to the United States Department of Health and Human Services, the measure was not endorsed and it was decided that the measure “requires modification or further development”. More particularly, the report provides: Read More

Opioid Safety, Respiratory Compromise

Does CMS’ Proposed Quality Measure on Patient Monitoring Adequately Address Patient Safety?

by Michael Wong

(This article first appeared in Becker’s Clinical Quality & Infection Control.)

CMS is considering a proposed quality measure that would require “appropriate monitoring of patients receiving PCA [patient-controlled analgesia].” This measure seeks to address the high number of errors that occur with PCA, which unfortunately research shows happens all too frequently. 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, Patient Stories, Respiratory Compromise

PPAHS Presents at IHI Forum on How Patient Safety Checklist Helps Address Opioid Warnings from The Joint Commission

At the recent Institute for Healthcare Improvement (IHI) 24th Annual National Forum on Quality Improvement in Health Care.

The presentation focused on The Joint Commission Sentinel Event Alert on safe use of opioids in hospitals, which states:

“While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.”

Read More