The 5 most viewed healthcare posts on the Physician-Patient Alliance for Health & Safety (PPAHS) blog were from previous years. Although we would like to think that these posts were just great articles – in fact, they had more views in 2015 than any other post, including those posted this year – sadly we think that it just shows that the patient safety issues discussed still remain.
The Google trends analysis of “opioids” (shown below) demonstrates, for example, an increase in interest from 2005 until now:
Use of PCA Pumps Can Pose Patient Safety Risks
The use of PCA pumps has been an issue that has been discussed on the PPAHS blog since its inception in 2011. So, it is not surprising that 2 of the 5 most visited articles in 2015 are about PCA.
Pat Iyer, who is a nurse consultant and the podcast moderator at PPAHS, wrote “Patient Controlled Analgesia (PCA) Pumps: The Basics” (2012). This article discusses how PCA pumps work and concerns with their use:
Concerns have been identified in the last few years about the hazards of PCA by proxy, that is allowing nurses and family members to activate the PCA pump on behalf of the patient. Overdoses of medication have occurred due to this practice, which is now being discouraged. Careful PCA pump programming and patient selection, as well as vigilant monitoring for the patient’s responses to medication are essential to provide a safe delivery of pain relief. There have been tragic instances of overdoses delivered through PCA pumps, resulting in respiratory arrest and brain damage. Continuous electronic monitoring using a pulse oximeter and a capnography machine detect drops in oxygen and increases in carbon dioxide, thus alerting clinicians to the risks of respiratory depression.
In “3 Risks with Managing Pain with Patient-Controlled Analgesia (PCA) Pumps” (2012), key risks to keep in mind when managing PCA are discussed:
Risk #1 – The potential for receiving too much medication may occur
Risk #2 – Injury and death can occur even if there are no errors with the PCA pump
Risk #3 – Patient is monitored with oximetry alone
Post-Surgical Patients Require Better Monitoring
According to the HealthGrades study of patient safety in American hospitals, “failure to rescue” and postoperative respiratory failure (also known as “Code Blue”) are the first and third most common patient safety related adverse events affecting Medicare patients accounting for 113 events per 1,000 at-risk patient admissions.
In the article “Post-Surgical Patients Require Better Monitoring”, PPAHS encouraged the adoption of the Anesthesia Patient Safety Foundation (APSF) recently released recommendations to improve the safety of patients through continuous monitoring after surgery.
To highlight and re-emphasize these 2011 APSF recommendations that were released in 2011, the APSF issued a video in 2014 calling for what Dr. Robert Stoelting, president of APSF referred to as “a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.” The APSF video can be viewed by going to http://apsf.org/resources/oivi/
Too Many Alarms May Compromise Health Outcomes
The Joint Commission issued Sentinel Event Alert #50 “Medical device alarm safety in hospitals” and has made improved alarm management a national patient safety issue.
To help achieve this national goal, we discussed infographs from The Joint Commission and ECRI as two resources that might be helpful. These info graphs are shown below:
Preventing Maternal Death
According to the CDC, the maternal death rate in the U.S. has more than doubled since 1987.
In “Mother Dies After Childbirth – What you need to know about Amniotic Fluid Embolism Now”, Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant, PPAHS) discussed a rare, but life threatening condition – amniotic fluid embolism.
The death of a 32-year old Colleen Celia prompted the article’s composition. The young mother died from amniotic fluid embolism, where amniotic fluid enters the mother’s bloodstream.
Wrote Ms. Razzano:
An amniotic fluid embolism occurs when amniotic fluid or fetal material enters the maternal bloodstream, possibly by passing through tears in the fetal membranes. It’s likely that amniotic fluid contains components that cause an inflammatory reaction and activate clotting in the mother’s lungs and blood vessels. This should be a red alert to the clinician and activate a proactive treatment and prevention plan.
However, amniotic fluid embolisms are rare — and it’s likely that some amniotic fluid commonly enters the maternal bloodstream during delivery without causing problems. It’s not clear why in some cases this leads to an amniotic fluid embolism.