Tag: BLOOD CLOTS

Patient Safety Weekly Must Reads (June 3, 2017)

This week’s must reads focus on patient safety tools.

This week in #patientsafety, PPAHS announced our position that all patients receiving opioids must be monitored with capnography. From around the web, the American Journal of Nursing summarized venous thromboembolism (blood clots) guidelines from American College of Chest Physicians, Ontario released a dataset and tool to explore opioid-related morbidity and mortality, and Pain Medicine News discussed a researcher’s exploration of alternatives to opioids. Continue reading “Patient Safety Weekly Must Reads (June 3, 2017)” →

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.

Top 10 Articles of 2016

Happy Holidays!

We’d like to wish you a safe and healthy 2017.

As we prepare for 2017, we reflect back on the top 10 articles from 2016.

Opioid Safety

  1. Physicians on Surgeon General’s Letter on Opioid Epidemic: Survey Results. The Surgeon General issued an Open Letter on the Opioid Epidemic. We looked into how clinicians and other patient safety experts felt about it.
  2. The U.S. Opioid Epidemic In Numbers. Related, Advance for Nurses generated an infographic summarizing your responses.
  3. 12 Years of Event-Free Opioid Use. In 2016, St. Joseph’s/Candler Health System celebrated 12 years free from Serious Adverse Events related to Opioid-Induced Respiratory Depression since the implementation of its continuous monitoring program.

Alarm Safety

  1. 3 Ways to Make Opioids Safer. Peggy Lange, RT, Director of the Respiratory Care Department at St. Cloud Hospital, discussed the importance of setting alarm thresholds for each patient in this podcast.
  2. Drawn Curtains, Muted Alarms, And Diverted Attention Lead To Tragedy In The Postanesthesia Care Unit. Sadly, alarms on the monitoring equipment used to alert healthcare professionals to changes in the patient’s cardiac and respiratory status were muted in one tragic death of a 17-year-old.
  3. A New Tool to Predict Respiratory Failure: An Interview with Hiroshi Morimatsu, MD, Ph.D. Could this multi-parameter indicator help counter alarm fatigue?

Bloot Clots Safety

  1. New PPAHS Campaign Targeting Orthopedic Venous Thromboembolism. VTE is the third-most prevalent reason for readmission after surgery, and about 1 million hip and knee replacement surgeries happen each year in the U.S.
  2. Physician-Patient Alliance Partners with World Thrombosis Day. As part of our new campaign, we partnered with World Thrombosis Day in 2016. Looking forward to working together in 2017.
  3. Why Bundled Payments for Joint Replacement May Be Risky for Patients. We took a look at whether patients are receiving evidence-based or reimbursement-based care under the Bundled Payments model.

Special Mention

  1. Why All Medical Schools Must Incorporate Quality Improvement and Patient Safety into Their Curriculums. This position by Molly Siegel generated plenty of engagement on the Twittersphere and is a theme that cuts across all of our priority areas.

Patient Safety Weekly Must Reads (December 2, 2016)

This week in #patientsafety, we look at the fact that opioid safety has yet again made the list of the ECRI Institute’s Top 10 Technology Hazards and we look at some key aspects of St. Joseph/Candler’s success in its continuous electronic monitoring program. From around the web, we share a video explaining how opioids cause harm and how their overprescription leads to drugs piling up in cupboards at home. We also share a story of a mother who died from blood clots – the coroner says her death was preventable.

From PPAHS:

Opioid Safety is again an ECRI Top-10 Health Technology Hazards for 2017. This is bittersweet. Bitter, because this problem is a major epidemic that has been going on for too long; sweet, because at least the topic is getting the attention it deserves.

Preventing Opioid-Related Adverse Events with Capnography. Continuous electronic monitoring has helped reduce serious adverse events related to opioid-induced respiratory depression at St. Joseph/Candler.

From Around the Web:

How the powerful opioid fentanyl kills. A video from the CBC explains how opioids work, and how they cause harm. Great for explaining the opioid epidemic to a lay audience.

Unused Opioids Pile Up in Medicine Cabinets, While Overprescribing Contributes to National Epidemic. Researchers at Johns Hopkins University School of Medicine, Baltimore, have found that health care providers dispense far more medicine than is necessary to treat pain after pediatric outpatient surgery.

Mum who died of blood clots two weeks after giving birth could have been saved, finds coroner. Marie Tompkins died from a blood clot. The coroner says the doctor failed to refer her to a scan that could have detected it.

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.

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” →

Preventing Blood Clots in Pregnant Mothers: PPAHS Releases Web-Enabled Application of OB VTE Safety Recommendations

The risk of blood clots in pregnant mothers is almost ten times more likely than a non-pregnant woman.

To help prevent blood clots in pregnant mothers, the Physician-Patient Alliance for Health & Safety (PPAHS) has released a web-enabled application of the OB VTE Safety Recommendations. The OB VTE application can be found at http://recommendations.ppahs.org/account/login Continue reading “Preventing Blood Clots in Pregnant Mothers: PPAHS Releases Web-Enabled Application of OB VTE Safety Recommendations” →

Keeping Pregnant Mothers Safe from Blood Clots: Managing the Health Care Risk in Obese Patients

Preventing blood clots in pregnant mothers poses significant health care challenges. The risk of blood clots in pregnant mothers is almost ten times more likely than a non-pregnant woman. These patient safety risks increase for pregnant mothers who are obese. In the United States, more than two-thirds of adults are obese. Continue reading “Keeping Pregnant Mothers Safe from Blood Clots: Managing the Health Care Risk in Obese Patients” →