Patient Safety

We Must Get Better at Detecting Patient Deterioration

Editor’s Note: This editorial from the desk of PPAHS’s Executive Director urges clinicians to do better at detecting patient deterioration. Patient monitoring is a combination of the use of technology in the hands of clinicians adequately trained on its use.

By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety)

ECRI Institute recently released its “2019 Top 10 Patient Safety Concerns.” In releasing its top 10 patient safety concerns, ECRI said:

This annual top 10 list helps organizations identify looming patient safety challenges and offers suggestions and resources for addressing them.

One of these 10 patient safety concerns in ECRI’s list is – Detecting Changes in a Patient’s Condition.

Why is this important?

Like a canary in a coal mine to detect carbon monoxide and other toxic gases, which alerted miners of potential dangers, being alerted to a change in a patient’s conditions provides the opportunity for clinicians to intervene.

Read More

Opioid Safety, Respiratory Compromise

5 Steps for Preventing Opioid Harm to Patients

By Stephanie Uses, PharmD, MJ, JD (Patient Safety Analyst, ECRI Institute), Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety), and Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

Inadequate monitoring for respiratory depression in patients receiving opioids poses the greatest risk and potentially resulting harm to patients. ECRI Institute recently released the 2016 Top 10 Patient Safety Concerns for Healthcare Organizations and assigned inadequate monitoring its highest risk map of 80: Read More

Alarm Fatigue, Must Reads

Weekly Must Reads in Patient Safety (Dec 5, 2014)

The Agency for Healthcare Research and Quality (AHRQ) estimates that 1.3 million fewer patients were harmed in U.S. hospitals from 2010 to 2013. AHRQ attributes this to “focused and widespread efforts to reduce surgical-site infections, adverse drug events and other preventable incidents.” Read More

Alarm Fatigue, Patient Stories, Respiratory Compromise

Making the Case for Maximum Alarm Management and Prevention of Alarm Fatigue

By Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant)

17-year old Mariah Edwards went in for a procedure that is performed countless times each year – a tonsillectomy. Recovering after the successful and very routine procedure, she was administered a dose of fentanyl to manage her pain. Although she was monitored continuously electronically, one of the attending nurses admitted on discovery that the monitor was muted for sound.

The settlement: $6 million. But, what really is $6 million to the parents of Mariah Edwards who have lost a child? What is the emotional toll to her nurses and other caregivers? Read More