Category: Practices & Tips

Patient Safety Tip of the Week: Dental Patient Safety

This article was first published in Patient Safety Solutions on March 15, 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

We were recently asked why we haven’t done any columns on dental patient safety. While over the years we’ve encountered a few minor safety issues in dental cases in hospitals, we’ve never looked at the broader issue of safety in dental practice where it is usually practiced – outside the hospital.

Continue reading “Patient Safety Tip of the Week: Dental Patient Safety” →

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” →

Minnesota RTs Help Implement Continuous Capnography Program

peggy lange — Peggy Lange, BA, RRT (RT Department Director, St. Cloud Hospital in St. Cloud, MN)

A recent article published by the American Association for Respiratory Care (AARC) has highlighted how respiratory therapists (RT) can play an integral role in using capnography to detect the signs of respiratory depression. The post focuses on the experiences of Peggy Lange, BA, RRT (RT Department Director, St. Cloud Hospital in St. Cloud, MN).

Over a three month period, St. Cloud Hospital ran a pilot program to test the effectiveness of continuous capnography monitoring Center for Surgical Care, PACU, surgical care units, interventional radiology, electrophysiology lab, and emergency trauma center. The trial was successful, proving the monitors gave an early alert to the signs of respiratory distress, as well as resolving issues caused by nuisance alarms – particularly with patients experiencing sleep apnea or periods of hyperventilation. As a result, continuous capnography monitoring was implemented hospital-wide. Continue reading “Minnesota RTs Help Implement Continuous Capnography Program” →

5 Key Resources to Reduce the Risk of Respiratory Compromise with Patients with Sleep Apnea

In a recent interview with a spotlight on the RADEO guide, Dr. Thomas Frederickson, MD, FACP, SFHM, MBA highlighted obstructive sleep apnea (OSA) as a key contributing condition to greater opioid use risk.

“Sleep apnea is the number one risk factor for respiratory depression associated with the use of opioids.

[…] Patients with obstructive sleep apnea are dependent upon their arousal mechanism in order to avoid respiratory depression and eventual respiratory failure.”

In addition to being the #1 contributing risk to opioid-induced respiratory depression, OSA is also common and often under diagnosed. Dr. Frederickson states that between 7% and 22% of the adult population has a degree of sleep apnea.

The key question that arises, then, is how to better identify and account for OSA in patients receiving opioids? Here are 5 key resources to reduce the risk of respiratory compromise in this group. Continue reading “5 Key Resources to Reduce the Risk of Respiratory Compromise with Patients with Sleep Apnea” →

5 Key Steps to Assessing and Identifying At-Risk Patients for Respiratory Compromise

The cost of opioid-related adverse events, in terms of both human life and hospital expenses, remains at the forefront of the public eye. It has been estimated that yearly costs in the United States associated with opioid-related post-operative respiratory failure were estimated at $2 billion.

The Society of Hospital Medicine, which is the largest organization representing hospitalists and a resource for hospital medicine, recently released a comprehensive guide, “Reducing Adverse Drug Events Related to Opioids” (otherwise known as the RADEO guide).

To better understand the RADEO guide, the Physician-Patient Alliance for Health & Safety interviewed its lead author, Thomas W. Frederickson MD, FACP, SFHM, MBA. Continue reading “5 Key Steps to Assessing and Identifying At-Risk Patients for Respiratory Compromise” →

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” →

6 Reasons Why Surgeons Don’t Act Safely

Dr. Mark Davis, a gynecologic surgeon and operating room safety consultant, shares his insights on improving safety in the operating room and preventing sharps injuries.

By Mark Davis M.D. (author “Irresponsible: What Surgeons Won’t Tell You and How to Protect Yourself”)

I firmly believe that all surgeons want to protect their patients, and that no surgeon would want to injure their teammates or themselves. There are a variety of effective strategies for preventing sharps injuries. These include the use of safety sharps devices, safe techniques for handling and passing sharp instruments, effective and respectful communication among members of the surgical team, and safety checklists. It would be reasonable to expect that all surgeons would want to use them but the reality is, many do not. So, given that the majority of surgical sharps injuries can be prevented, why don’t all surgeons follow these simple precautions? Continue reading “6 Reasons Why Surgeons Don’t Act Safely” →

“Keep It On” Campaign: 8 Tips for Ensuring Children are Monitored Safely

By Lynn Razzano RN, MSN, ONCC Clinical Nurse Consultant for PPAHS

The Physician-Patient Alliance for Health & Safety was recently contacted by a mother whose one-year-old baby boy tragically passed away. The boy suffered from leukemia, had a successful bone marrow transplant, and had received fentanyl and methadone. Although monitored with a pulse oximeter, his nurses had difficulty keeping the monitor on his finger (they had used tape), which caused the oximeter to false alarm frequently and the alarms to be turned down. Continue reading ““Keep It On” Campaign: 8 Tips for Ensuring Children are Monitored Safely” →

Clinical Tip: Mother Dies After Childbirth – What you need to know about Amniotic Fluid Embolism Now

By Lynn Razzano, RN, MSN, ONCC

The Boston Herald recently reported that 32-year old Colleen Celia on January 15, 2014, shortly after giving birth to her fourth child. The young mother died from amniotic fluid embolism, where amniotic fluid enters the mother’s bloodstream. Continue reading “Clinical Tip: Mother Dies After Childbirth – What you need to know about Amniotic Fluid Embolism Now” →