In a recent article, Peter Pronovost, MD, PhD, FCCM (Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient; Member of the Physician-Patient Alliance for Health & Safety PCA Safety Panel and OB VTE Recommendations Working Group) asks a great question, “Patient Safety at 15: How Much Have We Grown?”.
Dr. Pronovost reflects on the past 15 years:
Fifteen-year anniversaries often come and go without fuss, overlooked in favor of those we can mark in full decades. Yet recently, at Johns Hopkins and nationally, we’ve crossed that mark for a couple of events in patient safety that merit both celebration and reflection.
In January 2001, a series of lapses at Johns Hopkins led to the preventable death of Josie King, a toddler recovering from second-degree burns before her condition deteriorated and she developed sepsis. That tragedy, and the June 2001 death of a healthy 24-year-old clinical trial participant, Ellen Roche, brought our organization to a crossroads. Were we going to circle the wagons or take an honest look at ourselves so that we could do better?
This week’s articles remind us that we can do better.
Practice Better Blood Clots Safety
The UK Mirror recently wrote about the tragic story of a young mother who died of a blood clot shortly after giving birth to her son:
A young mum-of-two collapsed and died from a blood clot in her heart just five weeks giving birth to her youngest son.
Jade Willingham was just 30 when she collapsed while out walking with her partner close to their home in Hull, East Yorkshire.
She was then rushed to hospital where she tragically died a short time later on New Year’s Day.
We believe that Blood Clots Safety consists of a four steps:
- assessing patients for risk of venous thromboebolism (VTE)
- providing the recommended prophylaxis regimen, including mechanical and pharmacological prophylaxis, as prescribed
- reassessing the patient every 24 hours or upon the occurrence of a significant event, like surgery, and
- ensuring that the patient is provided appropriate VTE prevention education upon hospital discharge.
To read note about Blood Clots Safety, please see these podcasts and videos, where clinicians speak about what you can do to improve patient safety and health outcomes.
Recognize the Risks of Opioids
A New York Times analysis of death certificates has found:
Drug overdoses are driving up the death rate of young white adults in the United States to levels not seen since the end of the AIDS epidemic more than two decades ago — a turn of fortune that stands in sharp contrast to falling death rates for young blacks.
Some surgeons are curbing the use of opioids post-operatively, reports Anesthesiology News:
The risks associated with opioid analgesics in the chronic pain setting have been well documented, and many pain management physicians have initiated steps to reduce their overall use of these agents for long-term treatment.
Now, surgeons in multiple specialties have begun to pay greater attention to their prescribing of opioids for even the short-term management of postoperative pain, for fear that their use even during the relatively short, two- to three-day postsurgical recovery period could lead to problems of abuse and misuse in their patients long after they have left the operating room.
We believe that Opioid Safety includes continuous electronic monitoring of patients:
Opioid Safety, for patients receiving opioids in hospital and healthcare facilities, is the management and minimization of the risks of respiratory compromise, adverse events, and death through continuous respiratory monitoring with pulse oximetry for oxygenation and with capnography for adequacy of ventilation.