Must Reads

Patient Safety Weekly Must Reads (November 18, 2016)

This week in #patientsafety, we shared our findings from our survey on responses to the Surgeon General’s letter on the opioid epidemic and put venous thromboembolism in the spotlight with a new partnership with World Thrombosis Day. From around the web, a mother penned an article about the tragic and preventable death of her son, Minnesota respiratory therapists are recognized for implementing a program to detect respiratory depression at St. Cloud Hospital in St. Cloud, MN, and the ECRI Institute released its top ten healthcare technology hazards of 2017 (undetected opioid-induced respiratory depression yet again makes the top five).


Physicians on Surgeon General’s Letter on Opioid Epidemic: Survey Results. In August, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic. We conducted a survey to gauge reactions to the Surgeon General’s appeal. Read More

Opioid Safety, Respiratory Compromise

3 Keys to Safer Pediatric Sedation

The American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) recently released “Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016”.

There are three keys to this update which offers “pediatric providers updated information and guidance in delivering safe sedation to children”: Read More

Opioid Safety, Respiratory Compromise

Top Five Patient Safety Interviews

In honor of the fifth anniversary of the Physician-Patient Alliance for Health & Safety (PPAHS), PPAHS today announced the top five patient safety interviews by PPAHS.

“To increase awareness and promote discussion about and practical solutions for patient safety issues, PPAHS interviews doctors, nurses, respiratory therapists, and patients’ families,” said Michael Wong, JD (Executive Director, PPAHS).

By the number of views, the five most popular interviews on the PPAHS YouTube channel are: Read More

Opioid Safety, Respiratory Compromise

Patients Need to Be Better Assessed for Respiratory Compromise

Editor’s Note: What might better assessment for respiratory compromise mean to a patient’s outcome? We ask this question in light of yesterday’s post on an assessment tool and the death of 17-year old Logan.

Yesterday, we posted on research by Hiroshi Morimatsu, M.D.,Ph.D (Okayama University Hospital, Okayama, Japan) and his colleagues on whether a patient pulmonary index could be a predictor of respiratory adverse events.

On July 23, 2007, 17-year old Logan died after successfully undergoing routine surgery to correct his sleep apnea. Read More

Opioid Safety, Respiratory Compromise

Opioid Pain Medication & Assessing the Risk of Respiratory Compromise: Pamela Parker, RN on the Death of Her 17 Year Old Son

In this Podcast with PPAHS, Pamela Parker, BSN, RN, CAPA describes her son, Logan, as “a red haired, fair skinned, seventeen year old fun big kid … [who] was very silly and … even embraced the term ‘goofy’.”

Logan had obstructive sleep apnea (OSA) with elements of central sleep apnea. He underwent surgery to have “his tonsils and his uvula removed, septum and his turbinate repaired. Basically, opening up the airway by removing the tissue in the back of his airway.” Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Six Nursing Lessons: Nurse and Mother Reflects on the Untimely Death of Her Teenage Son

In an article in ADVANCE for Nurses, Pamela Parker, BSN, RN, CAPA discusses lessons that she learned on the timely death of her teenage son, Logan:

On July 23, 2007, my 17-year old son Logan died after successfully undergoing routine surgery to correct his sleep apnea. As a recovery room nurse, I have often asked myself how this could have been prevented.

By writing these six lessons I learned, I hope that other loved ones may be saved, other families spared the agony of losing a cherished member.

Read More