Patient Safety

Patient Safety Awareness Week Needs to Be Every Week

By Sean Power

“Competent and thoughtful leaders contribute to improvements in safety and organizational culture.”

The Joint Commission, Sentinel Event Alert 57

Earlier this month, The Joint Commission released Sentinel Event Alert 57, The essential role of leadership in developing a safety culture, calling on leaders to prioritize and increase the visibility of everyday actions that create a culture of safety.

There is no better time to amplify that message than Patient Safety Awareness Week, March 12-18, and we are calling on leaders to make every week patient safety awareness week at their healthcare facilities. Read More

Must Reads

Patient Safety Weekly Must Reads (February 18, 2017)

This week in #patientsafety, we highlight an article by the author of the RADEO Guide. From around the web, a daughter nearly died of sepsis and a mother died from blood clots after giving birth; plus, a JAMA study on whether financial penalties work to reduce hospital readmission rates.


Preventing Opioid-Induced Respiratory Distress In An Outpatient Setting. The author of the Reducing Adverse Drug Events related to Opioids (RADEO) Implementation Guide shared precautions to take during procedures in the outpatient setting, as well as upon patient discharge.

From Around the Web:

My Daughter Nearly Died of Sepsis. Here’s How You Can Stay Safe. A mother tells the story of her daughter’s near-miss after going into septic shock.

Husband wins seven year medical negligence fight after death of wife, 29. In the UK, the husband of a woman who died from a blood clot 16 days after the birth of her daughter has won a medical negligence claim.

Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions. The prospect of financial penalty appears to reduce hospital readmission rates, according to this JAMA study.

Opioid Safety

Preventing Opioid-Induced Respiratory Distress In An Outpatient Setting

by Thomas W. Frederickson, MD, MBA, FACP, SFHM, Medical Director, Hospital Medicine, CHI Health

Thomas W. Frederickson MD, FACP, SFHM, MBA discusses the deadly combination of opioids and benzodiazepines in hospitalized patients. Please click on the image to listen to an interview with Dr. Frederickson on YouTube.

With the increasing volume of procedures being moved to outpatient settings, procedures and processes need to be in place to make ensure patient safety.

The Society of Hospital Medicine has released a set of guidelines to reduce opioid-related adverse events in a clinical setting titled the Reducing Adverse Drug Events related to Opioids (RADEO) Implementation Guide. I had the pleasure of leading the expert panel tasked with developing the guide. The manual is designed as a resource to help clinicians successfully implement a quality improvement program.

In this article, I want to focus on some key precautions to take during procedures in the outpatient setting, as well as upon patient discharge.

Read the full article on Becker’s Hospital Review.

Respiratory Compromise

5 Strategies to Keep Patients Safe When Receiving Opioids

The Physician-Patient Alliance for Health & Safety (PPAHS) had the pleasure of interviewing Thomas W. Frederickson, MD, FACP, SFHM, MBA – lead author of the Society of Hospital Medicine RADEO guide (“Reducing Adverse Drug Events Related to Opioids”).  The guide is a comprehensive clinician manual created with the aim to decrease opioid-related adverse events in an inpatient setting.

In the first of this two-part interview, Dr. Frederickson discusses five key steps to identify and address patient conditions that pose a greater risk of respiratory depression.  For readers that have yet to listen to the podcast, please click here; it’s an insightful interview relevant for any clinician working in quality improvement or directly with patients prescribed opioids.

In part two, interviewer Pat Iyer and Dr. Frederickson switches gears and focuses on monitoring issues associated with caring for at-risk patients.  You can watch/listen to the interview below: Read More

Opioid Safety, Practices & Tips

5 Key Steps to Assessing and Identifying At-Risk Patients for Respiratory Compromise

The cost of opioid-related adverse events, in terms of both human life and hospital expenses, remains at the forefront of the public eye. It has been estimated that yearly costs in the United States associated with opioid-related post-operative respiratory failure were estimated at $2 billion.

The Society of Hospital Medicine, which is the largest organization representing hospitalists and a resource for hospital medicine, recently released a comprehensive guide, “Reducing Adverse Drug Events Related to Opioids” (otherwise known as the RADEO guide).

To better understand the RADEO guide, the Physician-Patient Alliance for Health & Safety interviewed its lead author, Thomas W. Frederickson MD, FACP, SFHM, MBA. Read More

Opioid Safety, Respiratory Compromise

A How-To Guide for Reducing Adverse Drug Events Related to Opioids (RADEO)

By Sean Power

Respiratory compromise is the primary antecedent to ‘code blue’, the leading trigger of rapid response calls, and the number one cause of ICU admissions. Respiratory compromise is one of three indicators accounting for 66 percent of all preventable patient safety issues and causes higher mortality rates, longer hospital and ICU stays, and millions of healthcare dollars every year.

Respiratory compromise consists of respiratory insufficiency, distress, arrest, and failure. Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

Read More