This week in #patientsafety, PPAHS featured a video about Tyler, an 18-year-old who survived the surgery for a collapsed lung but not the recovery. He was receiving opioids via PCA pump and was found dead in bed. From around the web, two Canadian patient safety organizations are trying to measure patient harm in hospitals, a biochemist from the University of Colorado looks at NSAIDs and sepsis, and an answer to whether a stroke patient should be driven to the hospital. Read More
This week in #patientsafety, we released a video that 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. From around the web, a look at alarm fatigue, pre-surgical counselling on opioid use, and reactions to a sepsis awareness campaign.
Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video. Over 10 hours of in-depth interviews released by PPAHS in 2016 distilled into 9 minutes.
From Around the Web:
How Redesigning The Abrasive Alarms Of Hospital Soundscapes Can Save Lives. Alarm fatigue continues to be a problem at hospitals.
Here’s something that curbs opioid use: Pre-surgical counseling. This surgeon shows a video on opioid safety to patients before undergoing surgery, and says it works at reducing opioid use.
Sepsis awareness campaigner reacts to health board responses. Health boards in the UK are working on reducing sepsis, but some are wary of a widower’s awareness campaign.
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.
This week in #patientsafety, we marked Patient Safety Awareness Week.
We want every week to be patient safety awareness week, so we published an article about saying so. We also shared a story written by a mother whose son died after a nursing error. From around the web, we highlight research on sepsis and opioid prescribing practices. We also direct you to an article from Canada looking at whether patients should feel comfortable taking opioids after surgery.
Patient Safety Awareness Week Needs to Be Every Week. We join others in calling on leaders to make every week patient safety awareness week at their healthcare facilities.
A Nursing Error Led to My Son’s Unexpected Death. This is the story of how the unmonitored use of patient-controlled analgesia and nursing errors led to the unexpected death of a mother’s only child (and how it might have been prevented).
From Around the Web:
Researchers Identify Biomarker that Predicts Death in Sepsis Patients. Duke scientists have discovered a biomarker of the runaway immune response to infection called sepsis that could improve early diagnosis, prognosis, and treatment to save lives.
Surgeons were told to stop prescribing so many painkillers. The results were remarkable. Despite the clickbait-y headline, this Washington Post article is legitimate and tells the story of how Dartmouth-Hitchcock Medical Center reduced the number of opioid pills they prescribed.
Should I be concerned about taking opioids after surgery?. For those in Canada, here’s a Globe and Mail article asking whether patients should be afraid to take opioids after surgery. The comments are worth reading; and share your opinion if you feel it appropriate to do so.
This week in #patientsafety, we shared an article by Bradley Truax, MD, on pediatric sedation. We also shared a first-hand story written by the daughter of a patient who almost died of sepsis. From around the web, PIPSQC shared clinical videos on pediatric safety and a QI team implemented a very successful intervention for patients undergoing elective surgery.
Also, it’s Blood Clot Awareness Month! Tell us what your team is doing to improve blood clot safety.
Patient Safety Tip of the Week: Guideline Update for Pediatric Sedation. Continuing our efforts to bring in multiple #patientsafety perspectives, we have reposted an article on pediatric sedation safety (with permission).
I am running 50 miles for Sepsis, because more needs to be done. The daughter of a man who almost died from sepsis tells her story in this heartfelt first-hand account.
From Around the Web:
Children’s Hospitals’ Solutions for Patient Safety (SPS) – Prevention Bundle Videos. On the topic of pediatric safety, the Paediatric International Patient Safety and Quality Collaborative (PIPSQC) shared some great videos on pediatric safety in a clinical setting.
Impact of a peri-operative quality improvement programme on postoperative pulmonary complications. A quality improvement team cut postoperative pulmonary complications in half with a perioperative intervention.
Blood Clot Awareness Month 2017: “Know More, Share More”. March is Blood Clot Awareness Month. Share what your team is doing to improve blood clot safety.
Editor’s Note: We came across a story by Jayne Bissmire, a woman running to raise funds for the UK Sepsis Trust. We were moved by how Jayne tells her story of how sepsis–a life-threatening condition that happens when the body’s response to an infection injures its own tissues and organs–has impacted her life by nearly taking her father from her.
We know now from research that sepsis accounts for more 30-day readmissions and is more costly than heart attacks, heart failure, chronic obstructive pulmonary disease and pneumonia. Behind these numbers-driven research papers, though, are the people whose lives are impacted by the condition.
Here is a first-hand account from one such person. Thank you, Jayne, for sharing your story and that of your father with our community of supporters.
My Sepsis Story
by Jayne Bissmire
I am running 50 miles for Sepsis, because more needs to be done. Read More
This week in #patientsafety, all quiet on the PPAHS front. We’re working on a few longer-form pieces and podcasts, so stay tuned! From around the web, our top news picks for the week focus on ambulatory care, sepsis, and painkiller prescriptions in Canada.
Nothing this week.
From Around the Web:
The Joint Commission publishes ambulatory care, office-based surgery chapters. The chapters describe how ambulatory care organizations and office-based surgery practices apply The Joint Commission’s requirements for patient safety.
Sepsis drives more readmissions than medical conditions tracked by CMS. Sepsis accounts for more 30-day readmissions and is more costly than heart attacks, heart failure, chronic obstructive pulmonary disease and pneumonia, according to new research in JAMA.
Guidelines for prescribing painkillers are silent on acute-pain treatment. In Canada, new national standards for prescribing painkillers do not address treating patients with acute pain–and some are questioning whether Health Canada’s rejection of a request to expand the scope of the standards was the right decision.
This week from PPAHS and around the web, we celebrate our 5th anniversary with some sharable tips for improving #patientsafety. We’ve also found 2 great studies and an interesting infographic about the opioid epidemic.
Sepsis occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail.
A recent Vital Signs Report issued by the CDC finds that sepsis begins outside of the hospital in nearly 80% of patients.
Additionally, 7 in 10 patients with had recently used health care services or had chronic diseases requiring frequent medical care. The report continues with 5 key steps clinicians can take to prevent sepsis from occurring.