Category: Patient Safety

Preventing medical errors during a transfer of care

A transfer of care can result in a medical error. In this joint article between the Canadian Patient Safety Institute and the Physician-Patient Alliance for Health & Safety, Michael Wong, JD (Founder & Executive Director of the Physician-Patient Alliance for Health & Safety) and Stephen Routledge, MPH (Patient Safety Improvement Lead, Canadian Patient Safety Institute) discuss how medical errors during transfers of care can be prevented.

In particular, two key resources are referred to in the article.

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5 Troubling Healthcare Facts

The articles we have been reading this past week of January 22, 2018 discuss 5 troubling healthcare facts.

#1 Troubling Healthcare Fact – Not enough experienced nurses

Shawn Kennedy, MA, RN asks a very good question in the title of her article, “Experienced Bedside Nurses: An Endangered Species?”:

“The trend toward our hospitals being primarily populated with nurses with less than two years’ experience is worrisome.”

We don't have enough experienced #nurses #patientsafety Share on X

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Taking Fentanyl Can Kill You

Abstract: The lesson learned from the death of Michelle McNamara – taking opioids can kill you. The opioid fentanyl can cause delayed respiratory depression and tragically death, particularly when used in combination with other sedating drugs.

Michelle McNamara, the writer and wife of comedian Patton Oswalt, died unexpectedly in her sleep in April 2016. Mr. Oswalt says that her death was caused by a toxic mixture of fentanyl and other drugs. As reported by People:

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Capnography use associated with reduction of adverse outcomes during procedural sedation

Millions of gastrointestinal endoscopy are performed each year in the US, with colonoscopies making up the majority of such procedures. Research conducted by Michael W. Jopling, MD and Qiu Jiejing published in BMC Anesthesiology concluded that capnography use associated with reduction of adverse outcomes during procedural sedation.

Their research sought to “estimate the incidence of pharmacological rescue events and death at discharge from an inpatient or outpatient hospitalization where [gastrointestinal endoscopic procedures] GEP was performed with sedation, and to determine if capnography monitoring was associated with reduced incidence of these adverse outcomes.”

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Effective Hip Injury Management

With the right medical care, exercise and nutrition, patients can confidently mitigate the impact of a hip injury.

By Jennifer Dawson

Hip injuries are a cause for serious concern in all age ranges, but especially adolescents and the elderly. An unattended injury can cause growth impediments or restrict mobility. Scientific studies by JCCA even found that the effects of a hip fracture can create obfuscating symptoms having potential secondary effects. With the population of the USA aging it’s likely to become more important to consider how to prevent and manage hip injury. Doing this intelligently and in a time efficient manner is important, with family caregiving sometimes time consuming. This article will cover how to effectively manage a hip injury.

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The Top 12 Patient Safety Articles for 2017

In 2017, we had many interesting patient safety articles – from the PPAHS staff, our Executive Director, guest clinicians and patient safety advocates. Our top 12 patient articles for 2017 focus on the use and management of opioids, and the tragic loss of patient lives from failure to monitor opioid use appropriately:

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Have a Safe and Merry Christmas!

The Physician-Patient Alliance for Health & Safety wishes you, your family and friends a safe and merry Christmas.

Have a Safe and Merry Christmas!
Have a Safe and Merry Christmas!

While we don’t want to be alarmist, we hope that you are not admitted to a hospital this holiday season.

The Institute of Medicine in its 1999 report, “To Err Is Human” estimated 98,000 people a year die because of medical errors. Recently, John James, PhD reviewed the literature. Using a weighted average of four studies, he found annually at least 210,000 patient deaths were preventable harms in hospitals.

We invite you to watch our clinical education podcasts to hear the latest practices and recommendations from healthcare experts on how to keep you patients safe.

CMS Proposes Measuring Opioid Related Adverse Respiratory Events

Centers for Medicare & Medicaid Services (CMS) recently released its List of Measures under Consideration.

One of the measures under consideration is MUC17-210 which measures “Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events”:

“This measure will assess opioid related adverse respiratory events (ORARE) in the hospital setting. The goal for this measure is to assess the rate at which naloxone is given for opioid related adverse respiratory events that occur in the hospital setting, using a valid method that reliably allows comparison across hospitals.”

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