Weekly Must Reads in Patient Safety (Jan 30, 2015)

At a conference, clinicians were arguing about the use of technology – some wanted to use it, others wanted to wait until something better came along. The latter group was willing to risk ore adverse events and deaths, while “waiting” it out … although one wonders if they would feel this way if the life of a loved one was on the line …

We think we should make the best use of what we have and save lives now.

To improve patient safety, perhaps we just need to get smarter.

Smarter About Treating Pregnant Mothers

Joanne Jones family

This father and his children are now without a wife and mother, after the mother, Joanne Jones, suffered from a massive blood clot after safely delivering her son Riley.

We need to get smarter about using available information.

Would the use of the OB VTE Safety Recommendations, which we released with the Institute for Healthcare Improvement and the National Perinatal Association, have prevented the blood clot and saved Joanne Jones’ life?

Smarter About Monitoring Patients Receiving Opioids

The Physician-Patient Alliance for Health & Safety recently issued the following statement encouraging the continuous electronic monitoring of all patients receiving opioids:

To improve patient safety and save patients’ lives, we recommend adopting continuous respiratory monitoring of all patients receiving opioids with pulse oximetry for oxygenation and with capnography for adequacy of ventilation to improve timely recognition of respiratory depression, decompensation or clinical deterioration.

Thanks to @Brian_Wellons and @yesmedical for tweeting about this.

We need to get smarter about the use of respiratory monitoring technology – like pulse oximetry and capnography.

Smarter About the Use of Opioids

A recent study looked at data of nearly 57 million American women who were admitted for obstetric delivery between the years 1998 and 2011. The researchers found that “opioid abuse or dependence during pregnancy (n= 60,994) markedly increased the odds of obstetrical mortality.”

We need to get smarter about the use of opioids.

As Gina Pugliese, RN, MS (Vice president, Premier Safety Institute) recently remarked in commenting on a study looking at opioid use in common pediatric surgeries:

We need to promote the safe and responsible use of opioids. One place to start is with common procedures like tonsillectomies. The Motherisk Program shows us that opioids can be safely and effectively be replaced with non-opioid alternatives. That said, if opioids must be used, to prevent respiratory depression and improve safety, patients receiving opioids should be continuously electronically monitored.

Smarter About the Use of Nurses

Researchers recently looked at in-hospital deaths in a thousand ICUs in 75 countries. A high nurse to patient ratio in intensive care units was independently associated with a lower risk of in-hospital death, according to results from a study involving more than a thousand ICUs in 75 countries. Concluded the researchers:

Time constraints related to a reduced nurse to patient ratio may increase the likelihood of mistakes by creating a stressful environment with distractions and interruptions that adversely affect quality of care.

We need to get smarter about the use of nurses.

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