This year, the Physician-Patient Alliance for Health and Safety introduced a weekly round-up of must-read articles in patient safety. The hand-picked list has consistently seen high engagement from our dear readers.
With that in mind, we thought we would compile a list of the Top Patient Safety Must Reads of 2014. Read More
Do We Need to Start a Revolution? – This is the question asked by Fred N. Pelzman, MD, who writes:
Over and over again, we were told about the sorry state of the U.S. healthcare system, how we are first in cost and last in quality, and there’s something inherently wrong with the way “we” take care of people in this country.
The Physician-Patient Alliance for Health & Safety (PPAHS) is pleased to announce that it will be hosting a lunch and learn session on the recently released OB VTE Safety Recommendations at the upcoming annual conference of the American Congress of Obstetricians and Gynecologists (ACOG). The ACOG annual meeting is being held in Chicago from April 26-30, 2014. Read More
The Physician-Patient for Health & Safety (PPAHS) is pleased to announce that its presentation on the national survey of hospitals on patient-controlled analgesia (PCA) hospital practices was awarded the Permanente Journal Service Quality Award. The award was presented December 10, 2013 at The 25th Annual IHI National Forum on Quality Improvement in Health Care. Read More
The Physician-Patient Alliance for Health & Safety, the Institute for Healthcare Improvement and the National Perinatal Association are pleased to announce the release of safety recommendations targeting the prevention of venous thromboembolism (VTE) in maternal patients. Read More
by Sean Power
Last week, the Physician-Patient Alliance for Health & Safety presented two cases in which health care facilities reduced PCA-related adverse drug events with continuous electronic monitoring.
Experts estimate that anywhere from 600,000 to 2,000,000 PCA errors occur each year. As Dr. Richard Dutton, Executive Director of the Anesthesia Quality Institute, states, “PCA errors certainly occur, both in programming and in delivery, but any published estimate is likely to be only the tip of the iceberg.” Read More
We would like to thank all of those who submitted comments on the proposed quality measure being considered by CMS regarding the monitoring of patients using patient-controlled analgesia (PCA) pumps.
In the report submitted by the National Quality Forum to the United States Department of Health and Human Services, the measure was not endorsed and it was decided that the measure “requires modification or further development”. More particularly, the report provides: Read More
by Michael Wong
(This article first appeared in Becker’s Clinical Quality & Infection Control.)
CMS is considering a proposed quality measure that would require “appropriate monitoring of patients receiving PCA [patient-controlled analgesia].” This measure seeks to address the high number of errors that occur with PCA, which unfortunately research shows happens all too frequently. Read More
PCA-related device events are three times as likely to result in injury or death. As Tim Ritter (Senior Patient Safety Analyst, Pennsylvania Patient Safety Authority) reminds us, “Over the six-year period from June 2004 to May 2010, data collected by Pennsylvania Patient Safety Authority revealed that there were approximately 4,500 reports associated with PCA pumps. Moreover, U.S. Food and Drug Administration’s (FDA) Manufacturer and User Device Experience (MAUDE) database demonstrates that PCA-related device events are three times as likely to result in injury or death as reports of device events involving general-purpose infusion pumps.” Read More
At the recent Institute for Healthcare Improvement (IHI) 24th Annual National Forum on Quality Improvement in Health Care.
The presentation focused on The Joint Commission Sentinel Event Alert on safe use of opioids in hospitals, which states:
“While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.”