Top 5 Patient Safety Accomplishments in 2015 – Weekly Must Reads in Patient Safety (Dec 30, 2015)

The Physician-Patient Alliance for Health & Safety (PPAHS) wishes you a safe and healthy 2016.

Happy New Year image source:!_(8332272701).jpg
Happy New Year image source:!_(8332272701).jpg

As the New Year begins, we took a look back at what PPAHS has done to achieve the goal of improved patient safety and health outcomes. We found 5 patient safety accomplishments in 2015:

#1 – Reducing the Risk of Respiratory Compromise

In our effort to reduce the risk of respiratory compromise, PPAHS was one of nine key medical and healthcare organizations, who came together to launch the Respiratory Compromise Institute ( to drive actionable solutions that increase education about and reduce the incidence of respiratory compromise in inpatient hospital settings.

Organizations that form the Clinical Advisory Committee of the Respiratory Compromise Institute include:

  • American Association for Respiratory Care (AARC)
  • American College of Emergency Physicians (ACEP)
  • American Society of Anesthesiologists (ASA)
  • American Thoracic Society (ATS)
  • American College of Chest Physicians (CHEST)
  • National Association for Medical Direction of Respiratory Care (NAMDRC)
  • Physician-Patient Alliance for Health & Safety (PPAHS)
  • Society of Critical Care Medicine (SCCM)
  • Society of Hospital Medicine (SHM)

#2 – Preventing Blood Clots In Stroke Patients

The Stroke VTE Safety Recommendations were released at the International Stroke Conference (ISC)

These Stroke VTE Safety Recommendations provide 4 key steps “to help prevent deep vein thrombosis (DVT) and pulmonary embolism (PE) in stroke patients. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common peristroke complications. DVTs are found in 40% to 80% of stroke patients, and PEs are present in 10% to 15% of all stroke patients, with PEs accounting for 13% to 25% of early deaths after a stroke.1 Below we discuss these 4 steps from the new Stroke VTE Safety Recommendations and encourage all clinicians to assess and treat stroke patients for venous thromboembolism (VTE).”

#3 – Preventing Blood Clots in Pregnant Mothers

To help prevent blood clots in pregnant mothers, PPAHS released a web-enabled application of the OB VTE Safety Recommendations.

The OB VTE Safety Recommendations were developed with the advice and counsel of a panel of experts brought together by PPAHS. The Recommendations provide four concise steps that:

  1. Assess patients for VTE risk with an easy to use automated scoring system
  2. Provide the recommended prophylaxis regimen, depending on whether the mother is antepartum or postpartum.
  3. Reassesses the patient every 24 hours or upon the occurrence of a significant event, like surgery.
  4. Ensures that the mother is provided appropriate VTE prevention education upon hospital discharge.

The OB VTE application can be found here.

4 – Achieving Improved Nursing Care

In an effort to help understand and achieve improved nursing care, PPAHS conducted a survey of nurses. The 10-question survey looked at what nurses think about continuous monitoring practices. It was sent to nurses throughout the United States.

Preliminary results of this survey showed three technologies that nurses would like, and were presented at the ACI Medical Liability conference.

Sandra K. Hanneman, PhD, RN, FAAN (Jerold B. Katz Distinguished Professor for Nursing Research, University of Texas Health Science Center at Houston (UTHealth), School of Nursing, Center for Nursing Research) commented on the preliminary results. Noting that statisticians are currently analyzing the results, she said, “The preliminary results show that nurses would like patient monitoring technology that is wearable and wireless. Having such technology would mean patients are not tethered to machines and foster greater patient mobility.”

#5 – Promoting Clinical Best Practices

To help promote the spread of best clinical practices, PPAHS produced podcasts interviewing clinicians on what they have done to improve health and safety at their healthcare facilities.

An initial series of podcasts focused on preventing blood clots in pregnant mothers:

  • Risk of Blood Clots After Cesarean Delivery” featured Peter Cherouny, MD (Emeritus Professor, Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont, Chair and Lead Faculty of the Institute for Healthcare Improvement Perinatal Improvement Community).
  • Preventing Blood Clots in Pregnancy” interviewed Colleen Lee MS, RN (Maternal/Perinatal Patient Safety Officer, Montefiore Medical Center).
  • Managing the Healthcare Risk in Obese Patients” was a discussion with Lisa Enslow, MSN, RN-BC(Nurse Educator, Women’s Health and Ambulatory Care Services, Hartford Hospital in Hartford, Connecticut).

Future podcasts will feature clinicians discussing the benefits of continuous patient monitoring. “This clinical education series will feature doctors, nurses and respiratory therapists discussing how they have successfully implemented continuous patient monitoring in their hospitals,” said Michael Wong, JD (Executive Director, PPAHS). “The series will also address how these hospitals and clinicians were able to overcome challenges to implementing monitoring.”





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