Weekly Must Reads in Patient Safety and Health Care (August 28, 2015)

Patient safety and health care should be improved for post-operative patients.

This is particularly true regarding respiratory compromise, where researchers have found that better monitoring of patients could have prevented adverse event cases.

Image source: http://thedoctorweighsin.com/safety-of-post-surgical-care/

Pain Medicine News reports in “Respiratory Depression Injuries Overwhelmingly Preventable”:

Respiratory depression (RD) often strikes patients within 24 hours of surgery and causes death or brain damage in the most serious of these cases, yet these injuries are often preventable, a new study from the Anesthesia Closed Claims Project and Anesthesia Quality Institute found. 

More than 88% of the RD events that led to malpractice cases occurred within 24 hours of surgery, with 77% resulting in severe brain damage or death, according to a report in Anesthesiology (2015;122:659-665). Top causes were multiple physicians prescribing pain medications for the same patient, the layering on of sedatives atop opioid-based medications and inadequate responses or assessments by clinical staff.

However, the overwhelming majority of cases—97%—were judged to have been preventable if there had been better monitoring of the patients or a more adequate response once RD was identified, according to a team of researchers affiliated with the Anesthesia Closed Claims Project.

Supporting these findings is research published in Anesthesia & Analgesia, “Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study”, which found:

Hypoxemia was common and prolonged in hospitalized patients recovering from noncardiac surgery. The SpO2 values recorded in medical records seriously underestimated the severity of postoperative hypoxemia.

Threshold monitoring for patients on the general care floor may need to re-thought.

In this article “Improving the Safety of Post-Surgical Care”, J. Paul Curry says that physiologic threshold monitoring works great in the operating room, but it is unreliable on post-surgical floors.

What could help with management of post-operative patients?

Three resources discuss better management of post-operative patients:

  1. Capnography Monitoring – see these case studies in improving health outcomes (thanks @ORPatientSafety for the retweet!).
  1. Obstructive Sleep Apnea Screening – research shows that “oximetry alone is insufficient as a screening tool for OSA in obese children. In the future, other screening methods need to be explored.”
  1. Outpatient Surgery – provides 5 essentials in post-operative management.

One thought on “Weekly Must Reads in Patient Safety and Health Care (August 28, 2015)

  1. Now that we have a better handle on hospital surgery death rates.. IMO it is not out of the question hospitals with the worst surgery death rates may be using this to bury evidence of botched care..botched surgeries, botched diagnosis..

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