Weekly Must-Reads in Patient Safety and Health Care (November 6, 2015) – When False Alarms Pollute Intensive Care

We have plenty of patient safety articles to share with you this week. From advice for nurses on how to educate patients about opioid diversion to tips for preventing medical errors in long-term care, audiences across the health care spectrum will benefit from some weekend reading.

Prescription Painkiller Sales and Deaths: http://www.cdc.gov/drugoverdose/data/
Prescription Painkiller Sales and Deaths: http://www.cdc.gov/drugoverdose/data/

Practical Steps for Nurses to Reduce Prescription Opioid Diversion

We called attention to this story earlier this week and it warrants inclusion in these weekly must-reads.

Nurses play a role in helping to prevent opioid diversion and non-medical use. According to the authors, they can:

  • Teach patients about the risks of opioid diversion
  • Provide patients with information on the safekeeping and proper disposal of opioids
  • Track patients’ analgesic use to improve knowledge of prescription analgesic requirements for pain management.

When false alarms pollute intensive care

At the 2015 Computing in Cardiology conference, organized in conjunction with MIT, doctoral students tackled the problem of alarm fatigue by developing algorithms to improve the usefulness of alarms.

From the article:

“Two EPFL doctoral students created algorithms capable of eliminating false alarms that pollute intensive care units. To do this, they came up with the idea of pairing electrocardiogram data with optical waveform data. Their work has won top honors at the Computing in Cardiology conference at MIT.”

The students say they eliminated 87 percent of false alarms while effectively detecting real alerts.

Read the article here.

Algorithms used to tackle #alarmfatigue Click To Tweet

Why North Carolina Mom Believes Newborn Saved Her Life

“Everything happened so fast. The doctors have theories of what was going on, but can’t figure it out. Something to do with Shelly’s hormones during pregnancy changed the way her blood clotted.” –Jeremy Cawley, husband of Shelly Cawley

Shelly Cawley was diagnosed with a blood clot early during her pregnancy and had to deviate from her natural birth plan to deliver via cesarean section.

Shelly delivered a healthy baby girl yet she herself wasn’t waking up. The Concord, North Carolina couple thinks that the earlier blood clot in Cawley’s leg broke loose after the C-section, hitting her lungs. Skin-to-skin contact between mother and baby helped stabilize Shelly’s vitals.

Read the story here.

Peter Cherouny, MD, Emeritus Professor, Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont, Chair and Lead Faculty of the IHI Perinatal Improvement Community, has highlighted that pregnancy is a major risk factor for developing venous thrombosis and pulmonary embolism, especially following cesarean delivery.

According to Dr. Cherouny, “no patients are low risk.”

He states:

“All patients having cesarean delivery should have pneumatic compression devices.”

Download the PPAHS OB VTE Safety Recommendations for a checkable set of recommendations for preventing blood clots among obstetric patients.

What these female stroke survivors want South African women to know

Three South African women shared their stories about surviving a stroke.

Read their stories here.

5 things to know about capnography in cardiac arrest

Bob Sullivan, MS, NRP, paramedic instructor at Delaware Technical Community College, authored an article for emergency medical services personnel on five things to know about using waveform capnography to detect respiratory compromise.

  1. Loss of ETCO2 may be the first sign that CPR is needed
  2. Compression feedback devices measure CPR quality, ETCO2 measures how the body responds to it
  3. Waveform capnography guides ventilation rates and confirms airway placement
  4. Capnography helps determine when to terminate resuscitation — and when to continue efforts
  5. A spike in ETCO2 reading is the first sign of return of spontaneous circulation (ROSC), and a drop in ETCO2 is the first sign it is lost.

Hospital campaign puts pressure on ulcers

West Hertfordshire Hospitals NHS Trust in Watford, Hertfordshire, United Kingdom has had no case of grade 4 ulcers, the most severe, for over two years. Grade 3 ulcer count is down by 75 percent; grade 2 ulcers have reduced by 40 percent.

The hospital launched a campaign at the end of last year that:

  • Made pressure ulcer documentation easier to find and access
  • Reviewed equipment and purchased new pressure-relieving cushions and mattresses, and
  • Introduced a “skin champion” role on the ward, “which is a nurse who ensures collaborative work between the tissue viability team, nutritionists and continence team.”

Naloxone: Drug Whys

According to Mike McEvoy, columnist at ems1.com:

“Opioid overdoses are a major public health problem, surpassing motor vehicle crashes as a major cause of death for the past several years.”

Read a “comprehensive” overview of opioid reversal agent Naxolone here.

As Morbidly Obese Patients Increase, Multimodal Approach Advances

Morbidly obese surgery patients are becoming more prevalent in North America. Adele Budiansky, MD, resident at the University of Ottawa in Ottawa, Ontario, Canada and her colleagues prepared a narrative review summary and found that morbidly obese patients have an increased risk for postoperative sedation, respiratory depression, airway obstruction and hypoxemia.

No surprise to most.

They also found that multimodal analgesia in this population is beginning to be explored in the research as an opportunity to reduce the total amount of opioids and therefore risk of respiratory compromise.

Some have advocated for a multimodal approach to pain management that includes non-pharmacologic interventions. Multimodal administration of opioids may fit within this kind of broader pain plan.

PPAHS has made available the PCA Safety Checklist which includes obesity as one of many risk factors to consider for opioid administration.

Medication errors found in 1 out of 2 surgeries

New research found that some kind of mistake or adverse event happened during the perioperative period in 50 percent of operations and in five percent of observed drug administrations.

According to Karen C. Nanji, Massachusetts General Hospital Department of Anesthesia, Critical Care, and Pain Medicine, lead author of the report:

“We found that just over one in 20 perioperative medication administrations resulted in a medication error or an adverse drug event.”

Tip of the hat to @PeterCoffaro for sharing the article on Twitter.

Preventing medical errors in long-term care

An estimated 60,000 deaths can be attributed to pressure ulcer wounds according to Bardia Anvar, M.D., medical director of Skilled Wound Care, who advocates for simple strategies that nursing home administrators and clinical directors can take to help reduce the likelihood of pressure ulcers in long term care facilities.

These include, among others:

  • Implementing a communication log to improve communication between doctors and nurses
  • Make sure members of a health care team are formally introduced to one another, giving them an opportunity to discuss the course of patient care
  • Using checklists for important patient care events, and
  • Educating staff to reduce the incidence of pressure ulcers.

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