Weekly Must Reads in Patient Safety (May 15, 2015)

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:

Woman finally gets pregnant after trying for 4 years — but gets stroke and loses one of her twins in the process


Odd requests help stroke victim get proper care

odd requests

Woman sent home in taxi dies of blood clot

sent home

… And now this week’s must read tips.

Alarm Fatigue Can Be Defeated

According to The Joint Commission, alarm fatigue occurs when clinicians become desensitized or immune to the sound of an alarm. Fatigued clinicians may:
• Turn down alarm volume
• Turn off alarm
• Adjust alarm settings.

Readings from this week, offer two tips for better alarm management:

1.  Use Statistics – Anesthesiology News reports on a study conducted by Michael R. Pinsky, MD (Professor of Critical Care Medicine, Bioengineering, Anesthesiology, Cardiovascular Diseases, and Clinical/Translational Services, University of Pittsburgh School of Medicine):

“Using a statistical approach known as Random Forest modeling, real and artifact vital sign events from continuous monitoring data have been distinguished. The approach is an important step toward reducing the alarm fatigue that plagues so many health care practitioners.”

2.  Use Video Cameras – A patient safety team at The Children’s Hospital of Philadelphia used cameras mounted in patients’ rooms to analyze the problem of alarm fatigue. For this work, AAMI awarded the best research paper of 2014 in a journal dedicated to biomedical technology.

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Three Anesthesia Tips for Labor and Surgery

Three tips for safer anesthesia use from this week’s must reads:

1.  Continuously Monitor with Capnography – Current Opinion In Anesthesiology published a study by Van de Velde, M.D., Ph.D. (Professor and Chairman, Department of Anesthesiology, Catholic University of Leuven) that concludes: “Remifentanil PCIA is a valuable analgesic strategy whenever regional analgesia is contraindicated. Using it as first line strategy seems to be contraindicated because of significant respiratory side-effects to the mother. Whenever used advanced and continuous monitoring using capnography, saturation monitoring and one-to-one midwifery care are mandatory!”

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2. Screen for Sleep Apnea Before Surgery – In a recent article by the Cleveland Clinic, Silvia Neme-Mercante, MD cautions: “Patients with sleep apnea who are undergoing any type of surgery are at an increased risk for developing respiratory and cardiovascular complications in the period following the surgery.”

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3.  Use Ketamine for Pre-hospital Analgesia – Interesting article that discusses three reasons to use ketamine for pre-hospital analgesia saying, “Recently, ketamine has made resurgence in the areas of emergency and pre-hospital medicine, and for good reasons. Ketamine was first developed in 1962 and is on the WHO Model List of Essential Medications. Ketamine is commonly used for pediatric sedation in emergency or operating room settings prior to painful procedures. The safety profile and effectiveness of ketamine make it an ideal medication in the pre-hospital setting.

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