Tag: Patient Safety

Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring

The following is a position statement published by PPAHS. If you would prefer to view our statement as a PDF, please click here.

Much of the public attention has been focused on the harm caused by prescription use and abuse of opioids. However, there is another facet that must be focused on: opioid-induced respiratory depression in clinical settings. This includes patients undergoing moderate and conscious sedation, or recovering from procedures and managing pain using a patient-controlled analgesia (PCA) pump, particularly those during the postoperative period. Continue reading “Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring” →

Anesthesiology Standards Shouldn’t be Different in Hospital and Outpatient Settings

Written by Lynn Razzano RN, MSN, ONC-C (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety).

When preventable medical errors occur, one of the very first questions asked by patients, families, the legal system, the press, and the public is: “were appropriate care standards met?”. As a professional Registered Nurse, I look at this question from a quality and patient safety perspective to ask what could have been done differently? What are the best practice medical standards, and why are they not applied across the US health care systems? How applicable should the medical standard of care be? And how do we, as clinicians and patient advocates, define the best practice standard of care?

The reality is that the definition of best practice and standard of care differs between acute care hospital settings and outpatient surgery centers. And, even then, the standard of care being applied by the ambulatory surgical center, anesthesiologist and the gastroenterologist may not be the same. Continue reading “Anesthesiology Standards Shouldn’t be Different in Hospital and Outpatient Settings” →

Organizations Need to Collaborate To Improve Patient Safety

In an article published on March 13, the National Patient Safety Foundation (NPSF) announced the first day of Patient Safety Awareness Week, as well as their merger with the Institute for Healthcare Improvement (IHI). Most importantly, the now-joint organizations restated a potent call to action: that preventable health care harm is a public health crisis and requires a coordinated public health response.

The Physician-Patient Alliance for Health & Safety (PPAHS) echoes the call of NPSF and IHI for healthcare leaders to treat every week as patient safety week by initiating a coordinated public health response to improve patient safety and drive the collective work. Doing so would help ensure that patients, and those who care for them, are free from preventable harm.

Directly targeting preventable harm at the clinical level is a deeply interconnected – and nuanced – problem. It will take the concerted efforts of many stakeholders:

Clinicians, key to the development and implementation of patient safety initiatives and sharing their successes and failures.
Hospital administrators, capable of empower doctors, nurses, and other specialists by providing them with the resources to continuously improve quality of care.
The academic community, who can ensure that patient safety interventions are high-quality through peer review.
Patient safety organizations like the IHI and PPAHS, who can examine the big picture, spot trends, and call attention to highlights and lowlights.
Public health agencies at the state and federal levels, who can transform the efforts by stakeholders described above into policy.

Most importantly, it will also involve actively engaging patients, who can play an active role in ensuring the safety of their own care by knowing their medical history, understanding which questions to ask, speaking up when something does not seem right, and following the instructions of their doctors and nurses.

Integrating stakeholders from across all of these groups is essential for the success of any coordinated public health response. This is a key reason why the PPAHS Board of Advisors consists of representatives from each of these stakeholder groups. It is also why we choose to work in tandem with other organizations on priority areas such as respiratory compromise: initiatives need to involve multiple stakeholders who bring with them diverse perspectives and skill sets.

The Respiratory Compromise Institute (RCI) embodies this level of coordination. Consisting of members such as the Society of Hospital Medicine, American Association for Respiratory Care, and CHEST/American College of Chest Physicians, RCI is a collaborative effort to improve opioid safety.

A recently-released report by RCI exemplifies the outcome of coordination and collaboration. The report identifies eight distinct subsets of respiratory compromise that pose a high risk of patient harm – and, most importantly, could be prevented with early detection and intervention. The manuscript is the result of a workshop organized by the National Association for the Medical Direction of Respiratory Care to address the unmet needs of respiratory compromise across the clinical spectrum. The writing committee was comprised of a diverse set of clinicians focusing on respiratory ailments – a collaborative group consisting of doctors, nurses, and respiratory therapists. Read the report here.

These kinds of reports are just one step in improving patient safety and help set direction for coordinated responses. It is up to us as a public health community – clinicians, administrators, patient safety organizations, public health agencies, as well as patients – to use this knowledge and take action to transform the standard of care in hospitals across the nation.

Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video

The Physician-Patient Alliance for Health & Safety (PPAHS) has released a YouTube video which discusses in nine minutes how to improve opioid safety. The video features highlights from over 10 hours of in-depth interviews released by PPAHS in 2016; altogether, the podcast series has generated over 130,000 cumulative views on YouTube. The podcast series brings together physicians, nurses, and respiratory therapists discussing how they have improved opioid safety in their hospitals.

According to Michael Wong, JD, Founder and Executive Director of PPAHS:

“In just nine minutes, the video summarizes experiences of clinicians in improving opioid safety in their hospital or healthcare facility, and reminds us of the tragic consequences of adverse events and deaths that may ensue if clinicians and healthcare executives are not proactive in promoting safety. We hope that the video will energize quality improvement and patient safety teams to strive to reduce adverse events and deaths related to opioid use.”

The opioid epidemic was one of the most heavily-covered, and hotly-debated, topic in patient safety covered in 2016. This dialogue has been mostly centered around the effects of ‘street’ use and abuse of prescription painkillers. In contrast, the PPAHS podcast series aims to highlight the preventable harm of opioid-induced respiratory depression during hospital procedures. Continue reading “Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video” →

Patient Ambulation a Key Metric to Improved Health

The following is a first in a series of position statements. If you would like to read/download our position on ambulation

[download_after_email id=”35512″]
Movement is a critical factor to improving patient health. Patient ambulation, the ability to walk from place to place independently with or without an assistive device, is necessary to improve joint and muscle strength, as well as prevent pressure ulcers during extended bed rest. It is a critical factor in improving patient well-being while in hospital, as well as reducing total length of stay (LOS). Continue reading “Patient Ambulation a Key Metric to Improved Health” →

Highlights From Joan Rivers’ Death and Lawsuit

What lessons can we learn from the recently settled medical malpractice lawsuit against the clinic where Joan Rivers died days after undergoing a routine endoscopy? Continue reading “Highlights From Joan Rivers’ Death and Lawsuit” →

Pressure ulcers are a common hospital-acquired condition with far-reaching implications for patient safety. It is estimated that 2.5 million patients are affected by pressure ulcers annually in the U.S.; about 60,000 patients will die nationwide directly from pressure ulcers. The condition is extremely painful, costly (up to $11 billion each year in the U.S. alone), and largely preventable. Continue reading “Pressure Ulcer Prevention Tools Presented At ASHRM Conference” →

Patient Safety Weekly Must Reads (November 25, 2016)

This week in #patientsafety, we shine the spotlight on respiratory therapists for all the work they do in keeping patients safe. We also look at whether bundled payments for hip and knee replacements are potentially risky when it comes to safe care. From around the web, we feature a great article highlighting stories of patients found “dead in bed”, possibly from providing too much pain medication (long-time PPAHS supporters will be familiar with most of these stories). Continue reading “Patient Safety Weekly Must Reads (November 25, 2016)” →

Patient Safety Weekly Must Reads (November 11, 2016)

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)” →

Physician-Patient Alliance for Health & Safety