Category: Blood Clots

New PPAHS Campaign Targeting Orthopedic Venous Thromboembolism

PPAHS will be beginning a new #patientsafety campaign to develop practical solutions to help assess and prevent venous thromboembolism (VTE) in patients undergoing orthopedic procedures, particularly total knee and hip replacement.  More commonly known as blood clots, VTE consists of both deep vein thrombosis (DVT) and pulmonary embolisms (PE) .

In the past, we have focused on the issue of VTE regarding maternal patients and stroke patients.  In collaboration with panels of international health experts, PPAHS has developed the OB VTE Safety Recommendations and the Stroke VTE Safety Recommendations (both of which are free resources on our website).  Members of the panel included:

  • Atul Gawande, MD, MPH (Brigham and Women’s Hospital)
  • Peter J. Pronovost, MD, PhD, FCCM (Johns Hopkins Medicine)
  • Mark Alberts, MD, FAHA (Southwestern Medical Center)
  • Irene Katzan, MD, MS (Cleveland Clinic)
  • William M. Callaghan, MD, MPH (CDC)
  • Frank Federico, RPh (Patient Safety Advisory Group, The Joint Commission)
  • Mary D’Alton, MD (Columbia University Medical Center)

According to the CDC, VTE is estimated to affect 900,000 Americans annually.  It is a preventable, hospital-acquired condition that is responsible for 100,000 deaths each year.  The US Department of Health & Human Services (HHS) has also issued a statement identifying venous thromboembolism as the third most prevalent factor accounting for readmission 30-days after surgery (6.3%).

Hip and knee replacement operations are among the most commonly performed procedures in the U.S. About 1 million of these procedures are performed each year (for more on prevalence, see the study by Hilal Maradit-Kremers, MD, MSc et al, “Prevalence of Total Hip (THA) and Total Knee (TKA) Arthroplasty in the United States”).  The 30-day readmission rate following hip and knee replacement is 4.3% and 3.9% respectively, with the readmission rate rising to 7.8% 90-days after surgery.

Join us in our fight to prevent orthopedic venous thromboembolism (VTE).  

Over the next few months, we will be putting together an expert patient safety panel on orthopedic VTE to advise and help answer healthcare reporters’ questions, looking for interviewees for Patient Safety Podcasts (such as the series created in collaboration with the Society of Hospital Medicine), and for guest contributions to our blog.

Hypercoagulation and Blood Clots in Women: A Patient Safety Concern?

By Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

Editor’s Note: This is the first post in what we hope will become a regular series of opinion pieces which ask our readers to comment on what could be considered controversial. Maternal patients are at risk for venous thromboembolism (VTE, commonly referred to as blood clots), which has been identified as a patient safety issue. In this post, the question asked is whether the recent deaths of young women due to blood clots from taking birth control pills is also a patient safety issue. 

Being pregnant increases the risks of blood clots. “For pregnant women, the risk of VTE is 4-5 times higher than women who are not pregnant,” says Andra James, MD (Professor of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Virginia School of Medicine). “Moreover, this risk is at least twice as much following cesarean delivery.”

Hypercoagulation during pregnancy is likely an adaptive mechanism to reduce the risk of hemorrhage during and after the delivery process. Continue reading “Hypercoagulation and Blood Clots in Women: A Patient Safety Concern?” →

3 Ways To Improve Safety for Patient Safety Awareness Week

This week (March 13-19) is Patient Safety Awareness Week.

The National Patient Safety Foundation says the campaign is “designed to spark dialogue and promote action to improve the safety of the health care system for patients and the workforce.” Continue reading “3 Ways To Improve Safety for Patient Safety Awareness Week” →

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.

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

How much safer are we? – Weekly Must Reads in Patient Safety (Jan 29, 2016)

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:

Continue reading “How much safer are we? – Weekly Must Reads in Patient Safety (Jan 29, 2016)” →

Top 5 Health and Safety Posts for 2015

The top 5 health and safety posts for 2015 on the Physician-Patient Alliance for Health & Safety (PPAHS) blog demonstrate risk management concerns for monitoring patients to prevent respiratory depression, preventing blood clots, and the need to manage device alarms.

Continue reading “Top 5 Health and Safety Posts for 2015” →

Women Twice as Likely to Die in Childbirth in US Than Canada

By Sean Power

An article by The Globe and Mail highlights a World Health Organization (WHO) report showing that the United States is falling behind Canada when it comes to maternal mortality.

According to the WHO report, the US average declined to 14 maternal deaths per 100,000 live births in 2015; Canada’s figure sits at 7, where it was in 1990.

Continue reading “Women Twice as Likely to Die in Childbirth in US Than Canada” →

Weekly Must-Reads in Patient Safety and Health Care (November 6, 2015) – When False Alarms Pollute Intensive Care

We have plenty of patient safety articles to share with you this week. From advice for nurses on how to educate patients about opioid diversion to tips for preventing medical errors in long-term care, audiences across the health care spectrum will benefit from some weekend reading.
Continue reading “Weekly Must-Reads in Patient Safety and Health Care (November 6, 2015) – When False Alarms Pollute Intensive Care” →

Weekly Must-Reads in Patient Safety and Health Care (October 23, 2015) – Two-Time Stroke Survivor Hopes to Teach Others About F.A.S.T.

This week’s must-reads feature articles about multiple patient safety touchpoints, from an inspiring article about Catherine Zalewski, a 33-year-old mother of two, former Mrs. New Jersey and certified personal trainer, and two-time stroke survivor who is raising awareness for World Stroke Day, to a new report that pharmacist intervention can help reduce readmissions through postdischarge outreach phone calls.

The theme of this week’s must-reads is that patient safety can and is being improved at multiple touchpoints.

Continue reading “Weekly Must-Reads in Patient Safety and Health Care (October 23, 2015) – Two-Time Stroke Survivor Hopes to Teach Others About F.A.S.T.” →