Must Reads

Patient Safety Weekly Must Reads (April 8, 2017)

This week in #patientsafety, we released a video that summarizes experiences of clinicians in improving opioid safety in their hospital or healthcare facility, and reminds us of the tragic consequences of adverse events and deaths that may ensue if clinicians and healthcare executives are not proactive in promoting safety. From around the web, a look at alarm fatigue, pre-surgical counselling on opioid use, and reactions to a sepsis awareness campaign.

From PPAHS:

Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video. Over 10 hours of in-depth interviews released by PPAHS in 2016 distilled into 9 minutes.

From Around the Web:

How Redesigning The Abrasive Alarms Of Hospital Soundscapes Can Save Lives. Alarm fatigue continues to be a problem at hospitals.

Here’s something that curbs opioid use: Pre-surgical counseling. This surgeon shows a video on opioid safety to patients before undergoing surgery, and says it works at reducing opioid use.

Sepsis awareness campaigner reacts to health board responses. Health boards in the UK are working on reducing sepsis, but some are wary of a widower’s awareness campaign.

Must Reads

Patient Safety Weekly Must Reads (April 1, 2017)

This week in #patientsafety, we took a step back to develop more substantial pieces that will be published in the near future. From around the web, Dr. Pronovost describes the results of a peer-to-peer hospital review program; Healthy Canadians, a collaborative initiative by a number of agencies within the Government of Canada, is re-promoting a 2015 video about prescription drug abuse; and, an article on how to use pain medication more safely.

From PPAHS:

Nothing this week.

From Around the Web:

How peer-to-peer review helps hospitals. In light of last week’s article on the impact of inspections on patient safety, this article by Peter Pronovost, MD, who served on the PPAHS PCA Safety Panel, is particularly timely.

Jordan’s Story. In this YouTube video, listen to Jordan’s story and how his dependence on pain medication led to tragedy.

How to Avoid Opioid Addiction When You’re Prescribed Pain Medication. This article provides suggestions to make opioid use safer, such as knowing your risk factors, taking meds only as prescribed, and seeking non-opioid pain management treatments.

Must Reads

Patient Safety Weekly Must Reads (March 25, 2017)

This week in #patientsafety, we highlight again that it is Blood Clot Awareness Month. From around the web, three studies: one on the effect of hospital inspectors on patient safety; one on sepsis; and, one on the relationship between opioid supply levels and long-term use.

From PPAHS:

March is Blood Clot Awareness Month. Blood Clot Awareness Month is a time for us to highlight stories and resources that you can share with colleagues, patients, and loved ones to bring attention to blood clots.

From Around the Web:

When Hospital Inspectors Are Watching, Fewer Patients Die. A study published in JAMA Internal Medicine studied records of Medicare admissions from 2008 to 2012 at 1,984 hospitals and found that in the non-inspection weeks, the average 30-day death rate was 7.21 percent. But during inspections, the rate fell to 7.03 percent.

UAB study highlights risks of sepsis. A new study from researchers at the University of Alabama at Birmingham analyzing three different methods for characterizing sepsis has helped to illustrate the risk of death or severe illness attributable to the condition.

With a 10-day supply of opioids, 1 in 5 become long-term users. With an initial 10-day opioid prescription, about one-in-five patients become long-term users, according to data published Friday in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

Blood Clots

March is Blood Clot Awareness Month

Blood Clot Awareness Month logo

March is Blood Clot Awareness Month.

Spearheaded by the National Blood Clot Alliance, #BCAM is a time for patients, caregivers, healthcare professionals, and advocates to draw attention to deep vein thrombosis and venous thromboembolism.

According to the National Blood Clot Alliance:

“Blood clots do not discriminate. They can and do affect anyone from children to senior citizens, from professional athletes to mothers, women and men – no one is immune. Tragically, roughly 274 lives are lost each day in the U.S. simply because public awareness about life-threatening blood clots is so low.”

Blood Clot Awareness Month is a time for us to highlight stories and resources that you can share with colleagues, patients, and loved ones to bring attention to blood clots. Read More

Must Reads

Patient Safety Weekly Must Reads (March 18, 2017)

This week in #patientsafety, we marked Patient Safety Awareness Week.

We want every week to be patient safety awareness week, so we published an article about saying so. We also shared a story written by a mother whose son died after a nursing error. From around the web, we highlight research on sepsis and opioid prescribing practices. We also direct you to an article from Canada looking at whether patients should feel comfortable taking opioids after surgery.

From PPAHS:

Patient Safety Awareness Week Needs to Be Every Week. We join others in calling on leaders to make every week patient safety awareness week at their healthcare facilities.

A Nursing Error Led to My Son’s Unexpected Death. This is the story of how the unmonitored use of patient-controlled analgesia and nursing errors led to the unexpected death of a mother’s only child (and how it might have been prevented).

From Around the Web:

Researchers Identify Biomarker that Predicts Death in Sepsis Patients. Duke scientists have discovered a biomarker of the runaway immune response to infection called sepsis that could improve early diagnosis, prognosis, and treatment to save lives.

Surgeons were told to stop prescribing so many painkillers. The results were remarkable. Despite the clickbait-y headline, this Washington Post article is legitimate and tells the story of how Dartmouth-Hitchcock Medical Center reduced the number of opioid pills they prescribed.

Should I be concerned about taking opioids after surgery?. For those in Canada, here’s a Globe and Mail article asking whether patients should be afraid to take opioids after surgery. The comments are worth reading; and share your opinion if you feel it appropriate to do so.

Patient Safety, Patient Stories

A Nursing Error Led to My Son’s Unexpected Death

This is the story of how the unmonitored use of patient-controlled analgesia and nursing errors led to the unexpected death of a mother’s only child (and how it might have been prevented).

By Victoria Ireland

On Saturday, the 5th of November, 2011, my life fell apart when my only son Tyler left this world.

One week before that, on the morning of the 28th of October, I received a phone call that no mother ever wants to receive. I was asked to go immediately to the hospital. And when I arrived, I was told that Tyler was found unresponsive and had suffered two cardiac arrests. I never got to speak to Tyler again.

Those days will forever be etched in my memory. While my heart will always ache from the loss of Tyler, I am telling his story in the hope that it will help prevent similar tragedies and that no parent will have to endure the pain of losing their child to nursing errors and unmonitored use of patient-controlled analgesia (PCA) pumps.

Read the full story on The Doctor Weighs In here.

Patient Safety

Patient Safety Awareness Week Needs to Be Every Week

By Sean Power

“Competent and thoughtful leaders contribute to improvements in safety and organizational culture.”

The Joint Commission, Sentinel Event Alert 57

Earlier this month, The Joint Commission released Sentinel Event Alert 57, The essential role of leadership in developing a safety culture, calling on leaders to prioritize and increase the visibility of everyday actions that create a culture of safety.

There is no better time to amplify that message than Patient Safety Awareness Week, March 12-18, and we are calling on leaders to make every week patient safety awareness week at their healthcare facilities. Read More

Must Reads

Patient Safety Weekly Must Reads (March 11, 2017)

This week in #patientsafety, we shared an article by Bradley Truax, MD, on pediatric sedation. We also shared a first-hand story written by the daughter of a patient who almost died of sepsis. From around the web, PIPSQC shared clinical videos on pediatric safety and a QI team implemented a very successful intervention for patients undergoing elective surgery.

Also, it’s Blood Clot Awareness Month! Tell us what your team is doing to improve blood clot safety.

From PPAHS:

Patient Safety Tip of the Week: Guideline Update for Pediatric Sedation. Continuing our efforts to bring in multiple #patientsafety perspectives, we have reposted an article on pediatric sedation safety (with permission).

I am running 50 miles for Sepsis, because more needs to be done. The daughter of a man who almost died from sepsis tells her story in this heartfelt first-hand account.

From Around the Web:

Children’s Hospitals’ Solutions for Patient Safety (SPS) – Prevention Bundle Videos. On the topic of pediatric safety, the Paediatric International Patient Safety and Quality Collaborative (PIPSQC) shared some great videos on pediatric safety in a clinical setting.

Impact of a peri-operative quality improvement programme on postoperative pulmonary complications. A quality improvement team cut postoperative pulmonary complications in half with a perioperative intervention.

Blood Clot Awareness Month 2017: “Know More, Share More”. March is Blood Clot Awareness Month. Share what your team is doing to improve blood clot safety.

Hospital Acquired Conditions, Patient Stories

I am running 50 miles for Sepsis, because more needs to be done

Editor’s Note: We came across a story by Jayne Bissmire, a woman running to raise funds for the UK Sepsis Trust. We were moved by how Jayne tells her story of how sepsis–a life-threatening condition that happens when the body’s response to an infection injures its own tissues and organs–has impacted her life by nearly taking her father from her.

We know now from research that sepsis accounts for more 30-day readmissions and is more costly than heart attacks, heart failure, chronic obstructive pulmonary disease and pneumonia. Behind these numbers-driven research papers, though, are the people whose lives are impacted by the condition.

Here is a first-hand account from one such person. Thank you, Jayne, for sharing your story and that of your father with our community of supporters.

My Sepsis Story

by Jayne Bissmire

I am running 50 miles for Sepsis, because more needs to be done. Read More

Opioid Safety, Practices & Tips

Patient Safety Tip of the Week: Guideline Update for Pediatric Sedation

This article was first published in Patient Safety Solutions in August 2016. As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted this with permission.

By Bradley T. Truax, MD

Our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” noted numerous cases of death related to sedation in dental practices. The majority of those cases occurred in pediatric patients. Read More