Must Reads

Weekly Must Reads in Patient Safety (Apr 3, 2015)

Our must reads for this week focus on 5 key tips, which if followed, could save a life.

As well, if you tweet about patient safety, a big “thank you” – see if your name appears below in our retweet shout outs. Read More

Respiratory Compromise

Procedural Sedation guidelines for Tonsillectomy and Adenoidectomy: The Basics

By Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety)

The American College of Emergency Physicians (ACEP) defines procedural sedation as:

“a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia (PSA) is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently.”

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Alarm Fatigue, Practices & Tips

Clinical Tip: Alarm Fatigue the Newest Clinical Hazard

By Lynn Razzano RN, MSN, ONCC (Clinical Nurse Consultant)

Increasingly we are seeing publications, alerts and evidence of the clinical phenomena entitled: “Alarm Fatigue”. What is the scope of this latest hazard and what are the new implications for clinical practice change. Read More

Alarm Fatigue, Opioid Safety, Patient Stories, Respiratory Compromise

Adverse Drug Events Discussed at California Hospital Engagement Network

by Sean Power

The Physician-Patient Alliance for Health & Safety recently participated in a webinar hosted through the California Hospital Engagement Network, an organization that brings together hospitals to reduce patient harm by 40% and readmissions by 20% by the end of 2013.

The panel discussion looked at patient stories and best practices for preventing opioid related adverse events. The panelists included: 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

Opioid Safety, Patient Stories, Respiratory Compromise

Does CMS Proposed Measure for PCA Safety Go Far Enough?

by Michael Wong

(This article is reprinted with the permission of Patient Safety & Quality Healthcare (PSQH).)

This is the question that I have been asking myself ever since Centers for Medicare & Medicaid Services (CMS) recently announced proposed quality measures it is considering for adoption through rule making for the Medicare program. 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

Addressing The Joint Commission Opioid Warnings: A Case Study from Wesley Medical Center on Reducing Respiratory Depression and Improving Patient Safety

By Sean Power and Michael Wong

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

Respiratory depression has been associated with the use of opioid analgesics. However, a recent study by researchers at Wesley Medical Center in Wichita, Kan., suggests exhaled CO2 monitoring of patients using patient-controlled analgesia pumps could help reduce the occurrence of this adverse event. Specifically, Debra Fox, MBA, RRT-NPS, and Mark Wencel, MD, examined respiratory depression rates with the use of PCA pumps and intermittent IV opioids for pain management. Read More

Opioid Safety, Respiratory Compromise

Health Experts Discuss Four Flawed Monitoring Practices

by Sean Power

Recently four health experts participated in a webinar on The Joint Commission’s Sentinel Event Alert on the safe use of opioids. On the panel were patient safety experts including Dr. Frank Overdyk, Professor of Anesthesiology at Hofstra North Shore-LIJ School of Medicine; Ray Maddox, Director of Clinical Pharmacy, Research and Pulmonary Medicine at St. Joseph Candler; Tammy Haslar, Oncology Clinical Nurse Specialist at the Franciscan Alliance at St. Francis Health, and Debbie Fox, Director of Respiratory Care at Wesley Medical Center.

The panel discussed the role of continuous monitoring in opioid safety. To watch the entire webinar, please click here. Read More