In 2017, we had many interesting patient safety articles – from the PPAHS staff, our Executive Director, guest clinicians and patient safety advocates. Our top 12 patient articles for 2017 focus on the use and management of opioids, and the tragic loss of patient lives from failure to monitor opioid use appropriately:
Top 12 #PatientSafety Articles for 2017 Click To Tweet
#12 Patient Safety Article – Tyler’s Story: A Deadly PCA Medical Error
This is the story of how the unmonitored use of patient-controlled analgesia and nursing errors led to the unexpected death of this mother’s only child (and how it might have been prevented).
The mother of 18-year old Tyler recounts how after following successful surgery, Tyler was placed on a patient-controlled analgesia (PCA) pump to manage his pain.How the unmonitored use of PCA and nursing errors led to the unexpected death of this mother's only child #patientsafety #opioid Click To Tweet Number 12 #PatientSafety Article for 2017 - Tyler’s Story: A Deadly PCA Medical Error Click To Tweet
#11 Patient Safety Article – Capnography Monitoring of Five-Year Old Amber Athwal May Have Prevented Her Brain Damage
This article discusses the case of five-year old Amber Athwal. It is a tragic reminder of the dangers of dental sedation whenever adequate personnel and patient monitoring are not present.
Under general anesthesia, Amber underwent dental surgery to extract some of her teeth. A lawsuit claims that Amber suffered “profound neurological injuries” after being deprived of oxygen, while recovering from the procedure.Dangers of dental sedation whenever adequate personnel and patient monitoring are not present #patientsafety #opioids Click To Tweet Number 11 #PatientSafety Article for 2017 - #Capnography Monitoring of Five-Year Old Amber Athwal May Have Prevented Her Brain Damage Click To Tweet
#10 Patient Safety Article – Opioid Safety Starts with Informed, Mutual Decisions
“Updated guidelines that address postsurgical opioid use–guidelines that apply the same rigour as the chronic pain guidelines–could create a significant positive impact on controlling the opioid epidemic, especially given the link between use for acute pain and long-term usage.”
Do you agree with this conclusion?#Opioid Safety Starts with Informed, Mutual Decisions #patientsafety Click To Tweet
#9 Patient Safety Article – Health data interoperability is a patient safety issue
This article by Tim Blake discusses why the safe and efficient sharing of patient health data between health providers and organisations is a patient safety issue. Mr. Blake explains why health data interoperability is a patient safety issue:
“The lack of willingness on the part of some healthcare providers and health IT vendors to safely and easily share patient health information with patients and other health providers is an unacceptable position in our increasingly digital age.”Health data interoperability is a #patientsafety issue Click To Tweet Number 9 Patient Safety Article - Health data interoperability is a patient safety issue Click To Tweet
#8 Patient Safety Article – New Report on Preventing Respiratory Compromise in Vulnerable Patients
The Respiratory Compromise Institute published a report titled “Respiratory Compromise as a New Paradigm for the Care of Vulnerable Hospitalized Patients”. The report notes that respiratory compromise is one of the most serious contributing factors to in-hospital patient mortality amongst common conditions. The team found that the development of in-hospital respiratory failure is associated with a mortality rate of nearly 40%; this rate of death is “twice as high as myocardial infarction and several times higher than for cancer, stroke, congestive heart failure, and renal failure.”Number 8 #PatientSafety Article for 2017 - Report on Preventing #RespiratoryCompromise in Vulnerable Patients Click To Tweet
#7 Patient Safety Article – This Sepsis Awareness Month, Suspect Sepsis – Save Lives
This article by Marijke Vroomen Durning, RN (Director of Content, Sepsis Alliance) asks us to be more aware of sepsis, because doing so may save a life:
“Healthcare providers can change this landscape through education, earlier detection, and management. Much like the golden hour for heart attacks or strokes, sepsis also has a golden hour. For patients with severe sepsis, chances of survival drop by almost 8% every hour treatment is delayed. We know that when identified early, sepsis can often be treated with fluids and antibiotics.”Number 7 #PatientSafety Article for 2017 - Suspect #Sepsis – Save Lives Click To Tweet @SepsisAlliance: Suspect #Sepsis – Save Lives #patientsafety Click To Tweet
#6 Patient Safety Article – Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video
In just nine minutes, this video by the Physician-Patient Alliance for Health & Safety 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.Number 6 #PatientSafety Article for 2017 - Nine Minutes to Improving #Opioid Safety Click To Tweet
#5 Patient Safety Article – Dental Patient Safety
This article by Bradley T. Truax, MD, discusses the need for greater safety during dental procedures and explores the spectrum of patient safety events that may occur in the dental office.Number 5 #PatientSafety Article for 2017 - Dental Patient Safety Click To Tweet
#4 Patient Safety Article – Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring
In this position statement, the Physician-Patient Alliance for Health & Safety sets forth its position that all patients receiving opioids must be monitored with continuous electronic monitoring. Monitoring is an important, but not all-encompassing, facet of opioid safety.
To read PPAHS’s position statement on ambulation, please click here.Monitoring is an important, but not all-encompassing, facet of #opioid safety Click To Tweet Patient monitoring technology should be a multiplying factor for hands-on, proactive care #patientsafety Click To Tweet Number 4 #PatientSafety Article - Patients Receiving #Opioids Must Be Monitored With Continuous Electronic Monitoring Click To Tweet
#3 Patient Safety Article – Patient Ambulation a Key Metric to Improved Health
In this position statement, the Physician-Patient Alliance for Health & Safety sets forth its position that movement is a critical factor to improving patient health. Patient ambulation, the ability to walk from place to place independently with or without an assistive device, is necessary to improve joint and muscle strength, as well as prevent pressure ulcers during extended bed rest. It is a critical factor in improving patient well-being while in hospital, as well as reducing total length of stay.
To read PPAHS’s position statement on ambulation, please click here.Number 3 #PatientSafety Article for 2017 - Patient Ambulation a Key Metric to Improved Health Click To Tweet
#2 Patient Safety Article – Capnography Monitoring During Conscious Sedation: Essential for Maintaining “Eyes and Ears” on Patients
In this clinical education podcast, Barbara McArthur (Advanced Practice Nurse, Sunnybrook Health Sciences Centre, Toronto, Canada) discusses why she chose capnography to monitor patients undergoing conscious sedation. Capnography monitoring should be used for patients receiving sedation whenever they “cannot be directly observed.”Click To Tweet #Capnography monitoring should be used for patients receiving sedation whenever they cannot be directly observed #patientsafety Click To Tweet
#1 Patient Safety Article – Highlights From Joan Rivers’ Death and Lawsuit
This article explores the lessons can we learn from the medical malpractice lawsuit against the clinic where Joan Rivers died days after undergoing a routine endoscopy?
The death of Joan Rivers prompted the Rivers family to focus on preventing similar incidents from happening again. All of us must do the same.Number 1 #PatientSafety Article for 2017 - Highlights From Joan Rivers’ Death and Lawsuit Click To Tweet