Promoting patient safety and improving the quality of patient care
Tag: Capnography
by Sean Power
What are Never Events?
Never Events are 28 preventable actions or mistakes that should never happen in a health care setting, which include: Continue reading “5 Questions Answered about Never Events and Patient-Controlled Analgesia Pumps”
by Michael Wong
(This article is reprinted with the permission of Patient Safety & Quality Healthcare (PSQH).)
This is the question that I have been asking myself ever since Centers for Medicare & Medicaid Services (CMS) recently announced proposed quality measures it is considering for adoption through rule making for the Medicare program. Continue reading “Does CMS Proposed Measure for PCA Safety Go Far Enough?”
Editor’s note – This article, “Three Tips For Decreasing Alarm Fatigue” is reprinted with the permission of Internal Medicine News and Hospitalist News, which publishes “news and views that matter to physicians”.
by Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety)
When patient monitor alarms sound too many times, this can discourage using the very monitors that are intended to keep patients safe and inform clinicians of a patient’s physiological state. However, research shows that using “smart alarm” technology and getting smart about alarm monitors can reduce clinically insignificant alarms. Continue reading “Three Tips For Decreasing Alarm Fatigue”
By Sean Power and Michael Wong
(This article first appeared in Becker’s Clinical Quality & Infection Control.)
Respiratory depression has been associated with the use of opioid analgesics. However, a recent study by researchers at Wesley Medical Center in Wichita, Kan., suggests exhaled CO2 monitoring of patients using patient-controlled analgesia pumps could help reduce the occurrence of this adverse event. Specifically, Debra Fox, MBA, RRT-NPS, and Mark Wencel, MD, examined respiratory depression rates with the use of PCA pumps and intermittent IV opioids for pain management. Continue reading “Addressing The Joint Commission Opioid Warnings: A Case Study from Wesley Medical Center on Reducing Respiratory Depression and Improving Patient Safety”
This article is reprinted with the permission of Patient Safety & Quality Healthcare (PSQH). Improving patient safety is one of the most urgent issues facing healthcare today. PSQH is written for and by people who are involved directly in improving patient safety and the quality of care.
According to ECRI Institute, an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care, alarm hazards are the number-one health technology hazard for 2013. Continue reading “Four Technology Recommendations to Reduce Alarm Fatigue”
by Sean Power
Recently four health experts participated in a webinar on The Joint Commission’s Sentinel Event Alert on the safe use of opioids. On the panel were patient safety experts including Dr. Frank Overdyk, Professor of Anesthesiology at Hofstra North Shore-LIJ School of Medicine; Ray Maddox, Director of Clinical Pharmacy, Research and Pulmonary Medicine at St. Joseph Candler; Tammy Haslar, Oncology Clinical Nurse Specialist at the Franciscan Alliance at St. Francis Health, and Debbie Fox, Director of Respiratory Care at Wesley Medical Center.
The panel discussed the role of continuous monitoring in opioid safety. To watch the entire webinar, please click here. Continue reading “Health Experts Discuss Four Flawed Monitoring Practices”
by Michael Wong
(This article first appeared in Becker’s Clinical Quality & Infection Control.)
More than 10 years ago, the Institute of Medicine in its landmark report, “To Err is Human” pointed out that at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented. IOM therefore called for the building of a safer healthcare delivery system.
In 2009, ten years after the original IOM report, Consumers Union, the non-profit publisher of Consumer Reports, concluded in its report “To Err is Human – To Delay is Deadly”:
“Despite a decade of work, we have no reliable evidence that we are better off today. More than 100,000 patients still needlessly die every year in U.S hospitals and health-care settings …”
Implementing change to decrease adverse events and to increase patient safety can be difficult for hospitals and healthcare facilities to implement. But, improvements are possible. Here are five tips to get you started. Continue reading “5 Tips on How to Improve Patient Safety With the Help of Technology”
by Dr. Frank Overdyk (Executive Director for Research, North American Partners in Anesthesiology, and Professor of Anesthesiology at Hofstra University School of Medicine)
Summary: The topic of who is a suitable candidate for outpatient surgery is front and center with productivity pressures being intense at ambulatory surgery centers. However, with surgery often comes the necessity of the use of opioids for pain control. Studies have shown that any patient receiving opioids may be at risk of postoperative respiratory depression and if undetected, respiratory arrest (also known as “Code Blue”). The most common antecedents to cardiopulmonary arrest are of respiratory origin. Respiratory decompensation—as evidenced by tachypnea, bradypnea, hypoxia, hypercarbia or changes in mental status—are often the earliest warning signs of physiologic instability. Monitoring respiratory function and level of consciousness are especially important in detecting and preventing adverse events for patients receiving opioids and sedatives. Continue reading “Monitoring the High-Acuity Patient: Does Risk Stratification Increase or Decrease Patient Safety?”
St. Joseph’s/Candler Hospitals reduced opioid-related events with patient-controlled analgesia (PCA) pumps. The hospitals are “error-free” since using “smart” PCA pumps with integrated capnography.
by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)
St. Joseph’s/Candler Hospitals (SJ/C) in Savannah, Georgia, are two of the oldest continuously operating hospitals in the US. About 10 years ago, SJ/C had three opioid-related events with patient-controlled analgesia (PCA) with serious outcomes over a two-year period.
Fortunately, none of these adverse events resulted in deaths, says Carolyn Williams, RPh, Medication Safety Specialist at SJ/C.
Since using “smart” PCA pumps with integrated capnography, SJ/C has been “error-free”. Continue reading “Case Study in How to Eliminate Adverse Events, Improve Patient Safety, and Reduce Healthcare Costs”
by Michael Wong
This is the question that I posed to lawyers, insurers, and healthcare professionals attending a major healthcare conference, the Crittenden Medical Conference. Continue reading “Improving Patient Safety in Hospitals: Can Hospitals Afford to Give Away Money? So Why Do Preventable Adverse Events Still Occur in Hospitals?”