Weekly Must Reads in Patient Safety (Apr 24, 2015)

Three themes for this week’s must reads:

  1. Dangers of Amniotic Fluid Embolism
  2. Assess and Treat Patients for Blood Clots
  3. Monitor Patients Receiving Sedation

1.  Dangers of Amniotic Fluid Embolism

Amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal material, such as hair, enters the maternal bloodstream.

Hilary Wilson suffered an amniotic fluid embolism during labor. She had a cardiac arrest and “died” for 11 minutes as her son was born. She was given a 30-percent chance of survival but thankfully woke up four days later.

Hilary Wilson

For more information on what you need to know about amniotic fluid embolism, please read this clinical tip by Lynn Razzano, RN, MSN, ONCC.

#amnioticfluidembolism is a rare but serious condition #ptsafety Click To Tweet 

2.  Assess and Treat Patients for Blood Clots

The Royal College of Obstetricians and Gynaecologists (RCOG) based in the UK that works to improve “women’s health care across the world” recently released revised guidelines for preventing and treating venous thromboembolism (VTE) during pregnancy, birth and following delivery:

The Green-top Guidelines provide information, based on clinical evidence, to assist clinicians with both the prevention and treatment of VTE in pregnant women, a condition which remains the leading direct cause of maternal death in the UK.

Royal College of Obstetricians and Gynaecologists guidelines to prevent and treat pregnant women for #bloodclots #VTE #ptsafety Click To Tweet

For guidelines developed by a group of renowned health experts and released by the Institute for Healthcare Improvement and the National Perinatal Association, with the Physician-Patient Alliance for Health & Safety, please see OB VTE Safety Recommendations. (Please note that PPAHS is currently developing a web-enabled version of the OB VTE Safety Recommendations. This web-enabled version will allow for such things as integration with electronic health records, data collection to aid research, and provide digital records to improve process. Downloading the pdf is not only free, but will add your name to a list of people to be notified when the web-enabled version is available.)

3.  Monitor Patients Receiving Sedation

According to recent research published in Pediatric Anesthesia, obesity is associated with increased odds of respiratory events and more frequent need for airway intervention in patients undergoing pediatric procedural sedation. The authors write:

Obesity is an independent risk factor for adverse respiratory events during procedural sedation and is associated with an increased frequency of airway interventions, suggesting that additional vigilance and expertise are required when sedating these patients.

#obesity is an independent risk factor for adverse #respiratory events #ptsafety Click To Tweet

For those concerned about possible increase in alarms associated with more monitoring, researchers at Case Western Reserve University, Rainbow Babies & Children’s Hospital, in Cleveland, Ohio, looked at monitoring in the NICU. They describe the issue as follows:

Increasing numbers of NICUs have designed single-family-rooms to create individualised environments for critically ill newborns and their families. While many advantages of these environments have been identified, one challenge is the ability to safely and effectively alert caregivers to alarms generated when physiologic derangements occur. When moving from a multibed environment to single rooms, there is a tendency for teams to select conservative alarm limits to reassure staff concerned about the loss of immediate visual contact with the child. While well intentioned, this may lead to an excessive number of alarms and what has been termed alarm fatigue: the tendency for caregivers to miss true alarms because the frequency of false alarms is overwhelming and dwarfs the number of true alarms.

Despite the potential harm from alarm fatigue in single-room NICUs, the researchers concluded that monitoring in a single-room environment is challenging, but safe and possible.

If continuously electronic monitoring is not used, the New Zealand Herald reports of this tragic death of 15-year old Matthew, who underwent emergency appendectomy. The attending nurse turned off Matthew’s pulse oximeter and now faces a disciplinary hearing:

A nurse faces a possible disciplinary hearing over her care of a 15-year-old boy who died while recovering from surgery done at the Greymouth’s public hospital

The children’s ward night-duty nurse documented his oxygen level as consistently 95 per cent overnight. At around 2am she reduced the oxygen to 3 litres. At 5 a.m. she turned off the oximeter machine – which measures a patient’s oxygen saturation level – as she had to care for a new admission. She did not assess Matthew again until 6.30 a.m. when she found him unresponsive.

monitor #patients receiving #sedation #ptsafety Click To Tweet




Leave a Comment, if You Care About Patient Safety