Weekly Must Reads in Patient Safety and Health Care (August 21, 2015)

Two lessons learned for this week’s must reads in patient safety and health care – (1) Monitor with Capnography to Improve Patient Safety and (2) Planning Helps Manage the Health Care Risk in Obese Pregnant Mothers.

1.  Monitor with Capnography to Improve Patient Safety

The Physician-Patient Alliance for Health & Safety (PPAHS) featured a video interview with Melissa Langhan, MD (Emergency Medicine, Yale School of Medicine) discussing case studies to improve patient safety through capnography:

Thanks so much for the retweets! – @ORPatientSafety, @SpangenbergLaw, @MDPatientSafety, @ParentNFamily, @AEGRIS2, @GxP_Services, @stock-runners, and @megha_prn.

Moreover, two hospitals shared their experiences of and endorsed the use of capnography:

(a)  White Memorial Medical Center

Richard Kenney, MSM, RRT, NPS, ACCS, RCP (Director, Respiratory Care Services) discusses why pulse oximetry is not being relied upon at White Memorial Medical Center and they are monitoring every use of patient-controlled analgesia with capnography:

With ETCO2 in conjunction with pulse oximetry the caregiver will know quickly that a condition for concern for the patients safety has been met and action needs to be taken immediately, thus reducing any harmful effects.  Being able to respond in a timely manner to prevent adverse situations will reduce adverse events, the potential for litigation, reduce unwanted admissions into the hospital, reduce length of stay and so on; which all greatly impact the bottom line.  The reputation of the facility, physicians, and staff will be preserved, but more importantly than anything else the avoidance of harm to patients is the ultimate goal.

Because of these shortcomings with monitoring with pulse oximetry, at our facility we have instituted mandatory capnography with each PCA device placed.  This specific model will automatically pause the infusion of pain medicine if an alarm limit is reached.  The pump cannot be reactivated until the patient has been assessed and the nurse or RCP has evaluated the patient to make sure they are out of harm’s way.  The nurses and RCP’s have stated that this system works.  With capnography used with PCA’s, it has and will continue to decrease the number of rapid response calls for this group of patients.

(b)  Advocate Christ Medical Center

Advocate Christ Medical Center says that it has “recently strengthened patient safety measures by expanding its use of capnography to monitor patients using patient-controlled analgesia (PCA) to regulate their pain after surgery.”

Dr. W. Boarden, Chairman of Anesthesia says, “Our widespread use of capnography to monitor a patient’s breathing is in line with the latest recommendations and underscores our dedication to patient safety.”

Two hospital case studies show monitoring with #capnography improves #patientsafety Click To Tweet

2.  Planning Helps Manage the Health Care Risk in Obese Pregnant Mothers

A study in JAMA Surgery suggests that nearly 50 percent of the blood clot or venous thromboembolism (VTE) cases reviewed at The Johns Hopkins Hospital were not actually preventable. Researchers say this shows the limits of penalty schemes aiming to improve the quality of care.

Before leaping to the conclusion that VTE prophylaxis doesn’t work (at least on fifty percent of patients), these points should be kept in mind:

However, even if about fifty percent may not be preventable, the other fifty percent are preventable.

Lisa Enslow, MSN, RN-BC (Nurse Educator for the Women’s Health and Ambulatory Care Services at Hartford Hospital) discusses four keys for managing the healthcare risk in obese pregnant mothers:


Keeping Pregnant Mothers Safe from Blood Clots: Managing the Healthcare Risk in Obese Patients
Keeping Pregnant Mothers Safe from Blood Clots: Managing the Healthcare Risk in Obese Patients
Planning Helps Prevent #BloodClots in #Obese #Pregnant #Mothers #ptsafety Click To Tweet

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