Are We Doing Enough to Prevent Patient Deaths? – Weekly Must Reads in Patient Safety (Feb 5, 2016)

Two patient deaths – one from alarm fatigue and one from a blood clot – make us stop and ask, “Are we doing enough to prevent patient deaths?

Death from Blood Clots

The Evening Post recently reported:

A teenage mother-to-be and her unborn baby were tragically killed by a DVT blood clot – just hours after finding out she was expecting a healthy boy.

Scarlett Holyoake, 18, was six months pregnant when she suddenly died from deep vein thrombosis after collapsing in her home.

Death from Blood Clots - Scarlett Holyoake was expecting her first baby with partner Sam Moulder -
Death from Blood Clots – Scarlett Holyoake was expecting her first baby with partner Sam Moulder –

We encourage the assessment of the risk of blood clots in all maternal patients. For more, please see the OB VTE Safety Recommendations.

Death from Alarm Fatigue

An article in The San Diego Union-Tribune reported that a California hospital was fined for causing the death of a patient:

The California Department of Public Health fined Vibra Hospital of San Diego nearly $50,000 Thursday for medical errors that caused a patient’s death in 2014.

According to a report released by the department, nurses and respiratory technicians ignored alarms and multiple electronic pager notifications that started about 3:30 a.m. on May 4, 2014, after part of a female patient’s ventilator became disconnected during her stay at the long-term care facility on Washington Street in Hillcrest.

Improved management of medical device alarms is a national patient safety goal of The Joint Commission.

A Medscape article, “Smarter Alarm Management Fights Alarm Fatigue”, the experiences of two hospitals are highlighted:

Wesley Medical Center was able to reduce and prioritize more than 10,000 daily alarms, reduce alarm incidence in its coronary care unit by 78%, and capture and distribute data from more than 600 medical devices for enhanced clinical surveillance by leveraging a combination of interdisciplinary input and alarm management technology

The Hospital for Special Care (HSC), located in New Britain and Hartford, Connecticut, is nationally recognized for advanced care and rehabilitation in pulmonary care, acquired brain and spinal cord injury, medically complex adults and pediatrics, neuromuscular disorders, and cardiac disease. In addition to reducing or eliminating nonactionable alarms, HSC’s goals for alarm management included collecting and distributing real-time data from more than 100 ventilators (each with its own set of alarms), as well as pulse oximeters, for enhanced, continuous patient surveillance, and analyzing objective, comprehensive clinical data after any patient incident to assess response processes and preventive measures.

Tell us what you are doing to help prevent patient deaths.

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