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”→
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”→
Leah walked into a Los Angeles hospital a healthy, 11-year old girl. She needed an elective surgery to repair a condition called pectus carinatum. Despite delays, the surgery went well, but Leah was in considerable pain; to manage it, she was given escalating doses of fentanyl, along with Ativan.
Her mother, Lenore Alexander, was concerned by Leah’s increasing unresponsiveness – but was assured by staff that Leah would be ready to walk out of the hospital in the morning. Exhausted, Lenore took a nap by her daughter’s bedside; it would be the last time Leah was seen alive. Lenore woke to find Leah dead in bed.
In 2012, Lenore wrote an article for PPAHS asking if continuous monitoring would have saved her daughter, Leah. The answer, then, was a resounding “yes”. During her hospital stay, Leah received only infrequent spot checks from staff to confirm her condition despite the administration of powerful opioids. If only she were monitored with capnography and pulse oximetry – we would not have another tragic story to tell.
We’re saying “hello” to December, and looking back at some of PPAHS’ top posts and tweets in November.
This month, as part of our new campaign targeting VTE in orthopedic patients, PPAHS was invited to become a partner of World Thrombosis Day! We also provided bittersweet coverage regarding opioid safety, including celebrating St. Joseph’s/Candler Health System’s (SJ/C) 12-years event-free and opioid safety’s place – once again – on ECRI’s Top 10 Health Technology Hazards.Continue reading “Top 10 Patient Safety Must Reads – November 2016”→
Opioid safety is one of the top patient safety concerns in the U.S.; with more than 2 million Americans dependent on opioids, opioid-related harm is an issue that has spans the continuum of clinical and public safety.
On August 25, 2016, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic. On the Surgeon General website, healthcare providers are encouraged to help solve the opioid epidemic.
The PPAHS conducted a survey to gauge how clinicians and the public felt about the Surgeon General’s recommendations to fight the opioid epidemic, with results released early November. Key aspects of the survey were recently featured in an article published by Advance for Nurses. The Advance Healthcare Network also distilled the survey’s top data points and recommendations.Continue reading “The U.S. Opioid Epidemic In Numbers”→
This year, St. Joseph’s/Candler Health System (SJ/C) celebrated 12 years free from opioid-related adverse events. The PPAHS had the pleasure of interviewing Harold Oglesby, RRT, Manager to uncover the SJ/C team’s learnings in implementing the quality improvement project.
From the inception of the project, continuous electronic monitoring with capnography has been a cornerstone technology to keeping patients at SJ/C safe. Mr. Oglesby and his team implemented a continuous monitoring program with capnography after identifying a need for reliable, early indication of patient decline in ventilation. Since the initial pilot, the monitors have shown tangible results:
“There was a couple of ‘aha’ moments when we saw that capnography giving us, sometimes an hour earlier, [indication] of a patient that was getting into distress.”
In a recent interview with Harold Oglesby, RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJ/C), our discussion focused on the success factors that contributed to SJ/C’s 12 years free from opioid-related adverse events.
This week in #patientsafety, the PPAHS interviewed Harold Oglesby, RRT, to uncover the strategies implemented to keep the Candler Hospital, St. Joseph’s/Candler Health System free from opioid-related adverse events for 12 years in a row. From around the web, we’ve found 3 articles highlighting national efforts to raise the bar in patient safety education and one on “routine” medical procedures that go wrong.Continue reading “Patient Safety Weekly Must Reads (November 11, 2016)”→
On August 25, 2016, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic. On the Surgeon General website, healthcare providers are encouraged to help solve the opioid epidemic:
“Our nation faces an opioid crisis. Health care providers are uniquely positioned to help communities and their patients #TurnTheTide on the opioid epidemic. Providers can be the solution. Join the movement. Sign the pledge.”