Two patient deaths – one from alarm fatigue and one from a blood clot – make us stop and ask, “Are we doing enough to prevent patient deaths?
Death from Blood Clots
The Evening Post recently reported:
A teenage mother-to-be and her unborn baby were tragically killed by a DVT blood clot – just hours after finding out she was expecting a healthy boy.
Scarlett Holyoake, 18, was six months pregnant when she suddenly died from deep vein thrombosis after collapsing in her home.
In a recent article, Peter Pronovost, MD, PhD, FCCM (Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient; Member of the Physician-Patient Alliance for Health & Safety PCA Safety Panel and OB VTE Recommendations Working Group) asks a great question, “Patient Safety at 15: How Much Have We Grown?”.
Dr. Pronovost reflects on the past 15 years:
The top 5 health and safety posts for 2015 on the Physician-Patient Alliance for Health & Safety (PPAHS) blog demonstrate risk management concerns for monitoring patients to prevent respiratory depression, preventing blood clots, and the need to manage device alarms.
The risk of blood clots in pregnant mothers is almost ten times more likely than a non-pregnant woman.
To help prevent blood clots in pregnant mothers, the Physician-Patient Alliance for Health & Safety (PPAHS) has released a web-enabled application of the OB VTE Safety Recommendations. The OB VTE application can be found at http://recommendations.ppahs.org/account/login Read More
Preventing blood clots in pregnant mothers poses significant health care challenges. The risk of blood clots in pregnant mothers is almost ten times more likely than a non-pregnant woman. These patient safety risks increase for pregnant mothers who are obese. In the United States, more than two-thirds of adults are obese. Read More
Before focusing on tips to defeat alarm fatigue and for making anesthesia safer for labor and surgery, three patient stories highlight the need for assessing patients for risk of venous thromboembolism: Read More
By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health and Safety)
[Editor’s note: We need a safer, more accurate, readily available diagnostic test for pulmonary embolism. Anna Hemnes, MD of Vanderbilt provides evidence that capnography may be such a test.] Read More
Happy Nurses Week!
This week’s must reads feature some interesting questions – and we would love to hear what you think on the following questions:
How can my wife be dead 48 hours after giving birth?
Three themes for this week’s must reads:
- Dangers of Amniotic Fluid Embolism
- Assess and Treat Patients for Blood Clots
- Monitor Patients Receiving Sedation
In recent editorial for Vascular Disease Management, health advocates write about the new Stroke VTE Safety Recommendations, which they say will provide four key steps to better health outcomes. Read More