Patient Safety

Capnography use associated with reduction of adverse outcomes during procedural sedation Continuous Patient Monitoring Reduces Likelihood of Adverse Events and Patient Deaths

Millions of gastrointestinal endoscopy are performed each year in the US, with colonoscopies making up the majority of such procedures. Research conducted by Michael W. Jopling, MD and Qiu Jiejing published in BMC Anesthesiology concluded that capnography use associated with reduction of adverse outcomes during procedural sedation.

Their research sought to “estimate the incidence of pharmacological rescue events and death at discharge from an inpatient or outpatient hospitalization where [gastrointestinal endoscopic procedures] GEP was performed with sedation, and to determine if capnography monitoring was associated with reduced incidence of these adverse outcomes.”

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Alarm Fatigue, Hospital Acquired Conditions

Advances in Alarm Management and Surveillance Monitoring

Written by James Welch, CEO Arc Biomedical Consultants (jwelch@arcbiomed.com)

james-welch

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

Opioid Safety, Patient Stories, Respiratory Compromise

Remembering Amanda: 7 Years After An Opioid-Related Death

This weekend marked the 7th anniversary of Amanda Abbiehl’s tragic death. Her story continues to remind us of the need for continuous electronic monitoring for all patients receiving opioids.

Amanda was 18-years-old when she was admitted to hospital for a severe case of strep throat. To help her manage the pain, she was placed on a patient-controlled analgesia (PCA) pump. The next morning, she was found unresponsive and died. Though PCA pumps are designed to deliver an exact dosage of opioid – in Amanda’s case, hydromorphone – getting the ‘right’ dosage is not a simple task. Too high a dosage can lead to respiratory depression, sometimes in minutes. Read More

Opioid Safety, Patient Stories, Practices & Tips, Respiratory Compromise

The Preventable Death of Paul Buisson: 3 Lessons on Preventing Opioid Death

The following is an excerpt of an article first published on The Doctor Weighs In on June 28, 2017. To read the full article, please click here.

In 2005, Paul Buisson, a celebrated Quebec animator and cameraman died as a result of opioid-related respiratory depression. What lessons can we learn more than a decade later? Read More

Opioid Safety, Position Statement, Respiratory Compromise

Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring PPAHS Position Statement on Continuous Monitoring

The following is a position statement published by PPAHS. If you would prefer to view our statement as a PDF, please click here.

Much of the public attention has been focused on the harm caused by prescription use and abuse of opioids. However, there is another facet that must be focused on: opioid-induced respiratory depression in clinical settings. This includes patients undergoing moderate and conscious sedation, or recovering from procedures and managing pain using a patient-controlled analgesia (PCA) pump, particularly those during the postoperative period. Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Tyler’s Story: A Deadly PCA Medical Error

Tyler was 18-years old when he was admitted to hospital for a pain in his chest.

It was a collapsed lung – the second time he had experienced one that year, and a condition that tall, young, slim males like Tyler can be prone to. To permanently correct the problem, Tyler underwent a procedure called pleurodesis, a common procedure to permanently prevent his lung from collapsing again. Upon the successful completion of the surgery, Tyler’s mother, Victoria Ireland said that she “breathed a sigh of relief”. Her son was going to be OK; all he needed to do was recover. Read More

Hospital Acquired Conditions, Opioid Safety, Patient Safety, Respiratory Compromise

Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video

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

Opioid Safety, Patient Stories, Respiratory Compromise

Opioid Deaths Are (Still) Preventable: Remembering Leah

Leah

Leah walked into a Los Angeles hospital a healthy, 11-year old girl.  She needed an elective surgery to repair a condition called pectus carinatum.  Despite delays, the surgery went well, but Leah was in considerable pain; to manage it, she was given escalating doses of fentanyl, along with Ativan.  

Her mother, Lenore Alexander, was concerned by Leah’s increasing unresponsiveness – but was assured by staff that Leah would be ready to walk out of the hospital in the morning.  Exhausted, Lenore took a nap by her daughter’s bedside; it would be the last time Leah was seen alive.  Lenore woke to find Leah dead in bed.

In 2012, Lenore wrote an article for PPAHS asking if continuous monitoring would have saved her daughter, Leah.  The answer, then, was a resounding “yes”.  During her hospital stay, Leah received only infrequent spot checks from staff to confirm her condition despite the administration of powerful opioids.  If only she were monitored with capnography and pulse oximetry – we would not have another tragic story to tell.

Now, on the 14th anniversary of Leah’s death, we ask the same question: would continous monitoring have saved Leah’s life?   Read More

Must Reads, Patient Safety

Top 10 Patient Safety Must Reads – November 2016

We’re saying “hello” to December, and looking back at some of PPAHS’ top posts and tweets in November.

Top Posts

This month, as part of our new campaign targeting VTE in orthopedic patients, PPAHS was invited to become a partner of World Thrombosis Day!  We also provided bittersweet coverage regarding opioid safety, including celebrating St. Joseph’s/Candler Health System’s (SJ/C) 12-years event-free and opioid safety’s place – once again – on ECRI’s Top 10 Health Technology Hazards. Read More

Must Reads

Patient Safety Weekly Must Reads (November 11, 2016)

This week in #patientsafety, the PPAHS interviewed Harold Oglesby, RRT, to uncover the strategies implemented to keep the Candler Hospital, St. Joseph’s/Candler Health System free from opioid-related adverse events for 12 years in a row.  From around the web, we’ve found 3 articles highlighting national efforts to raise the bar in patient safety education and one on “routine” medical procedures that go wrong. Read More