Category: 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.

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.

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 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.

Patient Safety Weekly Must Reads (March 4, 2017)

This week in #patientsafety, we shared an article on opioids in dentistry by Bradley Truax, MD. Outpatient Surgery covered our position statement on patient ambulation. From around the web, NPR wrote about dentists working to use fewer opioids, a hospital reduced nuisance alarms by 30%, and The Joint Commission issued a new Sentinel Event Alert on developing a culture of safety.

From PPAHS:

Patient Safety Tip of the Week: Dental Patient Safety. As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted an article on dental patient safety (with permission).

Push to Make Ambulation a Key Patient Recovery Metric. Outpatient Surgery covered our position statement on patient ambulation.

From Around the Web:

Dentists Work To Ease Patients’ Pain With Fewer Opioids. Dr. Joel Funari performs some 300 tooth extractions annually at his private practice in Devon, Pa. He’s part of a group of dentists reassessing opioid prescribing guidelines in the state.

Hospital’s program reduces nuisance alarms 30 percent. Nurses at Palomar Health in California were part of a study designed to reduce alarm fatigue. The health system decreased its alarms by nearly 30 percent.

Sentinel Event Alert 57: The essential role of leadership in developing a safety culture. “Competent and thoughtful leaders contribute to improvements in safety and organizational culture,” says The Joint Commission.

Patient Safety Weekly Must Reads (February 25, 2017)

This week in #patientsafety, we issued a statement on our position about the need to treat patient ambulation as a key metric. From around the web, ISMP released an updated self assessment for community/ambulatory pharmacy medication safety. We also found figures on opioid-related inpatient stays and emergency department visits by state from 2009-2014, and a dentist’s statement that the industry prescribes opioids “way too quickly”.

From PPAHS:

Patient Ambulation a Key Metric to Improved Health. PPAHS calls for dialogue at the clinical and governmental levels to identify and codify best practices that will prioritize patient ambulation.

From Around the Web:

ISMP Releases Updated Community/Ambulatory Pharmacy Medication Safety Self Assessment. Community and ambulatory pharmacy settings can now access a newly revised tool that will help them review and improve their medication safety practices.

Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014. This HCUP Statistical Brief presents data from HCUP Fast Stats on the national rate of opioid-related hospital inpatient stays and emergency department (ED) visits from 2005 to 2014.

Opioids unnecessary for dental work, doc says. The American Dental Association recently reported dentistry is responsible for prescribing 12 percent of all instant-release opioids.

Patient Safety Weekly Must Reads (February 18, 2017)

This week in #patientsafety, we highlight an article by the author of the RADEO Guide. From around the web, a daughter nearly died of sepsis and a mother died from blood clots after giving birth; plus, a JAMA study on whether financial penalties work to reduce hospital readmission rates.

From PPAHS:

Preventing Opioid-Induced Respiratory Distress In An Outpatient Setting. The author of the Reducing Adverse Drug Events related to Opioids (RADEO) Implementation Guide shared precautions to take during procedures in the outpatient setting, as well as upon patient discharge.

From Around the Web:

My Daughter Nearly Died of Sepsis. Here’s How You Can Stay Safe. A mother tells the story of her daughter’s near-miss after going into septic shock.

Husband wins seven year medical negligence fight after death of wife, 29. In the UK, the husband of a woman who died from a blood clot 16 days after the birth of her daughter has won a medical negligence claim.

Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions. The prospect of financial penalty appears to reduce hospital readmission rates, according to this JAMA study.

Patient Safety Weekly Must Reads (February 11, 2017)

This week in #patientsafety, we look at the CDC’s updated guidelines on opioids. From around the web, the CDC’s Opioid Guidelines are now available as a mobile app; a man experiences opioid-induced respiratory depression and dies after routine gallbladder surgery; and a study tries to test whether patient involvement actually improves patient safety.

From PPAHS:

Opioid Safety Starts with Informed, Mutual Decisions. Giving patients a decision-making role in their pain plan–and providing them with the information they need to arrive at informed mutual decisions–is a recurring theme in the CDC’s updated guidelines on opioids.

From Around the Web:

New CDC Opioid Guideline Mobile App Now Available. The CDC has released its free Opioid Guideline app, designed to help providers apply the recommendations of the CDC Guideline for Prescribing Opioids for Chronic Pain into clinical practice.

Man dies after routine gallbladder surgery. Gary Bougie was two months shy of his 36th birthday when he died. His family suspects he died from opioid-induced respiratory depression after going to the hospital for gallbladder surgery.

Achieving Real-Time Respiratory Depression Surveillance of Post-Surgical Patients. A focus on challenges of alarm management in caring for patients at risk for respiratory depression–includes strategies for better monitoring, referencing PPAHS’ national survey on PCA.

Patient Safety Weekly Must Reads (February 4, 2017)

This week in #patientsafety, all quiet on the PPAHS front. We’re working on a few longer-form pieces and podcasts, so stay tuned! From around the web, our top news picks for the week focus on ambulatory care, sepsis, and painkiller prescriptions in Canada.

From PPAHS:

Nothing this week.

From Around the Web:

The Joint Commission publishes ambulatory care, office-based surgery chapters. The chapters describe how ambulatory care organizations and office-based surgery practices apply The Joint Commission’s requirements for patient safety.

Sepsis drives more readmissions than medical conditions tracked by CMS. Sepsis accounts for more 30-day readmissions and is more costly than heart attacks, heart failure, chronic obstructive pulmonary disease and pneumonia, according to new research in JAMA.

Guidelines for prescribing painkillers are silent on acute-pain treatment. In Canada, new national standards for prescribing painkillers do not address treating patients with acute pain–and some are questioning whether Health Canada’s rejection of a request to expand the scope of the standards was the right decision.

Patient Safety Weekly Must Reads (January 28, 2017)

This week in #patientsafety, we announced a partnership with SONORIA to improve patient safety outside the operating room. From around the web, a couple of first-hand accounts from patients who use opioids to manage their chronic pain, plus a discussion on what nurses can do to prevent opioid-induced respiratory depression.

From PPAHS:

SONORIA and PPAHS Announce Alliance to Improve Clinical Collaboration. The new alliance will focus on promoting safety and optimize outcomes for patients undergoing procedures outside of the Operating Room.

From Around the Web:

I’m dependent on narcotics; that doesn’t mean I’m an addict. A first-hand account of somebody managing their chronic pain with opioids.

Doctors prescribed me pain meds but couldn’t help me get off them. What used to be an opioid-naive patient describes his experience with being prescribed opioids after a collision.

What Can Nurses do to Prevent Opioid-Induced Respiratory Depression? We spoke with Carla Jungquist, PhD, ANP-BC, of the University of Buffalo School of Nursing on how post-operative patients are assessed by nurses.