by Sean Power
July 23, 2013
With half of 2013 behind us, we took some time to reflect on the patient safety articles we’ve shared with this community. This reflection made us think about articles we haven’t shared–articles about which we wanted to write but did not have the bandwidth to do so at the time.
With that, I’d like to share four articles we think should be read by healthcare professionals working with patient-controlled analgesia.
The Case for Capnography: It Saves Lives
Patrick Moore, RRT
The article highlights the importance of checking for undiagnosed sleep apnea. Use the PCA Safety Checklist for every patient.
Better yet, monitor patients with capnography, so that, even if they experience undiagnosed sleep apnea, frontline staff members are still alerted of interruptions in the patient’s normal ventilation and respiratory process.
Patrick Moore, RRT, shares the experience of Torrance Memorial Medical Center, providing yet another case study of the impact of capnography monitoring on reducing adverse events.
“Capnography enables us to alleviate pain with confidence that the patient remains safe,” Lisa Refrezo, clinical nurse specialist for Torrance Memorial’s Med/Surg unit, says in the article.
The article cites research that may prove useful in making the case for capnography at your facility.
Patient Monitoring: The More the Better?
The author, John Bethune, describes in plain English why alarm fatigue is such a serious safety issue:
“Because most of the thousands of alarm events that occur each day in a typical facility do not require intervention, clinicians start to tune them out. As a result, The Joint Commission says, some critical alarms may be missed, with serious or fatal results.”
The article builds on the Torrance Memorial case study, providing a real world example of how one hospital balanced the pros delivered by expanding capnography with the cons created from alarm fatigue. The Torrance Memorial grapples with the challenge but agrees that the clinical benefits justify the program.
NHS must adopt a culture of “zero tolerance” for patient harm, Francis report says
Kris Vanhaecht discusses how the zero defect management program can improve healthcare facilities by applying its principles to patient care.
This concept should resonate with patient safety advocates as we move towards zero preventable deaths and work to eliminate needless patient harm.
To Do Less Harm, Know What You Don’t Know
Brian P. Dunleavy
On the topic of harm reduction, Brian Dunleavy’s article looks at the impact of poor communication, teamwork, leadership, and decision-making biases on patient safety in anesthesiology. Researchers identified these common factors after analyzing 9,500 patient claims.
According to the article, several case studies show that all clinicians, including anesthesiologists, tend to follow treatment guidelines on 50 percent of the time. While guidelines are not perfect they can provide a useful framework for communicating, leading, and making decisions—the same factors identified as risks for safe patient care.
What articles from the first half of 2013 would you recommend to the patient safety community?