Must Reads

Weekly Must Reads in Patient Safety and Health Care (September 25, 2015) – Risk Assessment Tools & Medical Errors

The two themes for this week’s must reads are risk assessment tools and medical errors.

Risk Assessment Tools

Nicole Humbert, PharmD, Trinity Hospital (Livonia, Michigan) and her colleagues analyzed 13,838 patients who received an opioid within 24 hours of surgery. Through their research, they have developed a risk assessment tool to identify those patients most at risk of opioid-induced respiratory depression:

According to Humbert, patients in the very-high-risk or high-risk groups would need to be monitored more carefully for OIRD, including more frequent assessment of vital signs and pulse oximetry monitoring.

Medical Errors

A report by Health Quality Ontario and the Canadian Patient Safety Institute discusses 15 “never events”. Some examples:

An infant abducted from a hospital. Surgery performed on the wrong side of the body. A patient dying because no one asked about his or her allergies.

The report provides “guidance on how institutions can prevent such occurrences and shift the culture to become more open and willing to report mistakes and problems.”

To help avoid medical errors, here are some articles that could help:

  1. Enroll in a Patient Safety Program – New York Law School created the Patient Safety Project.
  1. Bring Nurses Back to the Bedside – Rhonda Collins, MSN, RN writes, “Too often, nurses spend valuable time tracking down supplies, medications, or other care team members, filling out paperwork, and searching for test results.”





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