Category: Patient Safety

Physician-Patient Alliance Appoints Communications Director

The Physician-Patient Alliance for Health & Safety (PPAHS) would like to formally announce that Nicholas Wong has been appointed as Director, Communications.

Some readers of the PPAHS blog may have noticed that, over the past year, Nicholas has appeared alongside Sean (Community Manager) and Michael (Executive Director) as an article author. As Communications Director, he will be driving our communication strategy. Continue reading “Physician-Patient Alliance Appoints Communications Director”

Organizations Need to Collaborate To Improve Patient Safety

In an article published on March 13, the National Patient Safety Foundation (NPSF) announced the first day of Patient Safety Awareness Week, as well as their merger with the Institute for Healthcare Improvement (IHI). Most importantly, the now-joint organizations restated a potent call to action: that preventable health care harm is a public health crisis and requires a coordinated public health response.

The Physician-Patient Alliance for Health & Safety (PPAHS) echoes the call of NPSF and IHI for healthcare leaders to treat every week as patient safety week by initiating a coordinated public health response to improve patient safety and drive the collective work. Doing so would help ensure that patients, and those who care for them, are free from preventable harm.

Directly targeting preventable harm at the clinical level is a deeply interconnected – and nuanced – problem. It will take the concerted efforts of many stakeholders:

  • Clinicians, key to the development and implementation of patient safety initiatives and sharing their successes and failures.
  • Hospital administrators, capable of empower doctors, nurses, and other specialists by providing them with the resources to continuously improve quality of care.
  • The academic community, who can ensure that patient safety interventions are high-quality through peer review.
  • Patient safety organizations like the IHI and PPAHS, who can examine the big picture, spot trends, and call attention to highlights and lowlights.
  • Public health agencies at the state and federal levels, who can transform the efforts by stakeholders described above into policy.

Most importantly, it will also involve actively engaging patients, who can play an active role in ensuring the safety of their own care by knowing their medical history, understanding which questions to ask, speaking up when something does not seem right, and following the instructions of their doctors and nurses.

Integrating stakeholders from across all of these groups is essential for the success of any coordinated public health response. This is a key reason why the PPAHS Board of Advisors consists of representatives from each of these stakeholder groups. It is also why we choose to work in tandem with other organizations on priority areas such as respiratory compromise: initiatives need to involve multiple stakeholders who bring with them diverse perspectives and skill sets.

The Respiratory Compromise Institute (RCI) embodies this level of coordination. Consisting of members such as the Society of Hospital Medicine, American Association for Respiratory Care, and CHEST/American College of Chest Physicians, RCI is a collaborative effort to improve opioid safety.

A recently-released report by RCI exemplifies the outcome of coordination and collaboration. The report identifies eight distinct subsets of respiratory compromise that pose a high risk of patient harm – and, most importantly, could be prevented with early detection and intervention. The manuscript is the result of a workshop organized by the National Association for the Medical Direction of Respiratory Care to address the unmet needs of respiratory compromise across the clinical spectrum. The writing committee was comprised of a diverse set of clinicians focusing on respiratory ailments – a collaborative group consisting of doctors, nurses, and respiratory therapists. Read the report here.

These kinds of reports are just one step in improving patient safety and help set direction for coordinated responses. It is up to us as a public health community – clinicians, administrators, patient safety organizations, public health agencies, as well as patients – to use this knowledge and take action to transform the standard of care in hospitals across the nation.

“Good” Hospitals Require Real Leaders

The following is an excerpt of an article written by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety). It first appeared on Healthcare Business Today on April 9, 2017. To read the full article, please click here.

As the Executive Director of the Physician-Patient Alliance for Health & Safety, a non-profit whose mission is the improvement of patient safety, I am often asked how to tell a “good” hospital (i.e. patient safe) from a “bad” hospital (i.e. unsafe).

In thinking about “good” and “bad” hospital leadership, I am reminded of two discussions I had with hospital leaders – which leaders’ hospital would you rather be a patient at or, if you are a clinician, work at?

I spoke with the CEO of a hospital, who was dealing with the family of a child that had died within the hospital from opioid-induced respiratory depression. His clinicians had not employed continuous electronic monitoring with pulse oximetry for oxygenation or with capnography for adequacy of ventilation. Continue reading ““Good” Hospitals Require Real Leaders”

Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video

The Physician-Patient Alliance for Health & Safety (PPAHS) has released a YouTube video which discusses in nine minutes how to improve opioid safety. The video features highlights from over 10 hours of in-depth interviews released by PPAHS in 2016; altogether, the podcast series has generated over 130,000 cumulative views on YouTube. The podcast series brings together physicians, nurses, and respiratory therapists discussing how they have improved opioid safety in their hospitals.

According to Michael Wong, JD, Founder and Executive Director of PPAHS:

“In just nine minutes, the video 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. We hope that the video will energize quality improvement and patient safety teams to strive to reduce adverse events and deaths related to opioid use.”

The opioid epidemic was one of the most heavily-covered, and hotly-debated, topic in patient safety covered in 2016. This dialogue has been mostly centered around the effects of ‘street’ use and abuse of prescription painkillers. In contrast, the PPAHS podcast series aims to highlight the preventable harm of opioid-induced respiratory depression during hospital procedures. Continue reading “Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video”

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 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. Continue reading “Patient Safety Awareness Week Needs to Be Every Week”

Patient Ambulation a Key Metric to Improved Health

The following is a first in a series of position statements. If you would like to read/download our position on ambulation

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Movement is a critical factor to improving patient health. Patient ambulation, the ability to walk from place to place independently with or without an assistive device, is necessary to improve joint and muscle strength, as well as prevent pressure ulcers during extended bed rest. It is a critical factor in improving patient well-being while in hospital, as well as reducing total length of stay (LOS). Continue reading “Patient Ambulation a Key Metric to Improved Health”

SONORIA and PPAHS Announce Alliance to Improve Clinical Collaboration

The Society for Non OR Intervention and Anesthesia (SONORIA) and the Physician-Patient Alliance for Health & Safety (PPAHS) are pleased to announce their new alliance focused on promoting safety and optimized outcomes for patients undergoing procedures outside of the Operating Room. Wendy Gross MD, President of SONORIA and Michael Wong JD, CEO and Executive Director of PPAHS have each agreed to serve as advisors to their respective organization’s Boards. Continue reading “SONORIA and PPAHS Announce Alliance to Improve Clinical Collaboration”

Orthopedic VTE Safety Report Now Available

The Physician-Patient Alliance for Health & Safety (PPAHS) released findings on practical solutions to prevent venous thromboembolism (VTE) in patients undergoing hip and knee replacement in its Orthopedic VTE Safety Report.

The survey gathered 41 respondents from across the United States and targeted experts in orthopedics. The majority of respondents indicated that they were either physicians (42.5%) or nurses (32.5%). Those who elected to identify themselves as “Other” largely fell within four self-identified professions: nurse practitioners, physical therapists, program managers, and pharmacists. About 3 in 5 respondents indicated that their primary work setting was in Orthopedics.

Continue reading “Orthopedic VTE Safety Report Now Available”