Must Reads, Patient Safety

Top 10 Patient Safety Must Reads – November 2016

We’re saying “hello” to December, and looking back at some of PPAHS’ top posts and tweets in November.

Top Posts

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. Read More

Opioid Safety, Respiratory Compromise

Preventing Opioid-Related Adverse Events with Capnography

Patient Monitoring

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.”

Effective implementation is crucial whenever new technology is introduced in a clinical setting.  During our interview, Mr. Oglesby speaks to three key learnings to make continuous monitoring with capnography a success. Read More

Opioid Safety, Respiratory Compromise

Respiratory Therapists Are Integral to Reducing Opioid-Related Adverse Events

Harold Oglesby - Celebrating 10 Years's Event Free

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.

During the interview, Mr. Oglesby highlighted five key learnings from his experiences in implementing and continuously improving SJ/C’s QI initiative.  One of these learnings was the importance of involving Respiratory Therapists (RT) throughout the process. Read More

Must Reads

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. Read More

Opioid Safety, Respiratory Compromise

12 Years of Event-Free Opioid Use

The Physician-Patient Alliance for Health & Safety (PPAHS) recently interviewed Harold Oglesby RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJ/C).  

Read More

Must Reads

Top 10 Patient Safety Must Reads – October 2016

In October, the PPAHS celebrated it’s 5th anniversary.  In addition to building around the growing body of knowledge regarding accounting for OSA in patients receiving opioids, the PPAHS also announced a new campaign targeting VTE in orthopedic patients. Read More

Respiratory Compromise

New Guideline on Pre-Op Screening and Assessment for OSA

This article was first published in Patient Safety Solutions on October 11, 2016.  As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted this with permission.

By Bradley T. Traux, MD

Our regular readers are well aware of the numerous controversies and limited evidence base regarding perioperative issues in patients with known obstructive sleep apnea (OSA) or those suspected as being at high risk for OSA (see the list of prior columns at the end of today’s column).

The Society of Anesthesia and Sleep Medicine has just published “Guidelines on Preoperative Screening and Assessment of Adult Patients with Obstructive Sleep Apnea”. This is a most thorough evaluation of the evidence base regarding multiple issues related to OSA in patients about to undergo surgery. One is struck by the lack of strong evidence for almost all the recommendations in the guideline, though we are not surprised since we’ve previously discussed most of the controversial issues. Yet this consensus guideline uses common sense and is very practical and appropriately balances concerns for patient safety with utilization of resources and concerns over timing of surgery.

Below is their executive summary of the recommendations: Read More

Alarm Fatigue, Opioid Safety

3 Limitations to the Use of Pulse Oximetry

Image source: http://thedoctorweighsin.com/pulse-oximetry-false-alarms-on-post-surgical-floors/

Image source.

In PPAHS’ latest podcast, we spoke with 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 RADEO guide is a comprehensive clinician manual created with the aim to decrease opioid-related adverse events in an inpatient setting. Read More