Must Reads

Patient Safety Weekly Must Reads (December 2, 2016)

This week in #patientsafety, we look at the fact that opioid safety has yet again made the list of the ECRI Institute’s Top 10 Technology Hazards and we look at some key aspects of St. Joseph/Candler’s success in its continuous electronic monitoring program. From around the web, we share a video explaining how opioids cause harm and how their overprescription leads to drugs piling up in cupboards at home. We also share a story of a mother who died from blood clots – the coroner says her death was preventable.


Opioid Safety is again an ECRI Top-10 Health Technology Hazards for 2017. This is bittersweet. Bitter, because this problem is a major epidemic that has been going on for too long; sweet, because at least the topic is getting the attention it deserves.

Preventing Opioid-Related Adverse Events with Capnography. Continuous electronic monitoring has helped reduce serious adverse events related to opioid-induced respiratory depression at St. Joseph/Candler.

From Around the Web:

How the powerful opioid fentanyl kills. A video from the CBC explains how opioids work, and how they cause harm. Great for explaining the opioid epidemic to a lay audience.

Unused Opioids Pile Up in Medicine Cabinets, While Overprescribing Contributes to National Epidemic. Researchers at Johns Hopkins University School of Medicine, Baltimore, have found that health care providers dispense far more medicine than is necessary to treat pain after pediatric outpatient surgery.

Mum who died of blood clots two weeks after giving birth could have been saved, finds coroner. Marie Tompkins died from a blood clot. The coroner says the doctor failed to refer her to a scan that could have detected it.

Alarm Fatigue, Must Reads, Opioid Safety, Respiratory Compromise

Weekly Must Reads in Patient Safety (Oct 17, 2014)

Monitoring is the catch word for this week’s must reads. It keeps patients safe and prevents avoidable patient harm. While St Joseph/Candler Hospital just celebrated 10 years of being “event free”, each year an estimated 20,800 to 678,000 patients managing their pain with patient-controlled analgesia will experience life-threatening, opioid-induced respiratory depression. If you are scared about asking your caregivers about monitoring, just say Dr. Robert Stoelting (President, Anesthesia Patient Safety Foundation) told you to. Read More

Opioid Safety, Respiratory Compromise

Opioid Safety Experts Say Continuous Monitoring of Post-Surgical Patients Receiving Opioids Should Be Universal Standard

Continuous electronic monitoring of patients receiving opioids to manage their pain after surgery should be a universal standard of care, leading opioid safety experts said during a recent webinar.

The March 4, 2014 webinar was hosted Premier Safety Institute as part of their Advisor Live series. Read More

Alarm Fatigue, Respiratory Compromise

Harold Oglesby, Noted Opioid Safety Expert and Patient Safety Advocate, Joins Physician-Patient Alliance for Health & Safety Advisory Board

The Physician-Patient Alliance for Health & Safety (PPAHS) announced today that Harold Oglesby, Registered Respiratory Therapist (RRT), Manager, The Center for Pulmonary Health, Candler Hospital, and St. Joseph’s/Candler Health System (SJ/C), has joined the PPAHS Board of Advisors.

“On behalf of PPAHS, I am thrilled to offer the warmest of welcomes to Harold Oglesby as he joins our Board of Advisors,” said PPAHS Executive Director Michael Wong, JD. “As a well-respected authority on respiratory therapy and opioid safety, as well as a life-long advocate for patient safety, Mr. Oglesby embodies everything about our mission and shares our passionate commitment to improve patient health and safety.” Read More

Opioid Safety, Respiratory Compromise

St. Joseph’s/Candler Hospitals Nominated for Best of Respiratory Care: 8 Years of Event-Free Patient-Controlled Analgesia Monitoring, Improved Patient Safety, and Reduced Healthcare Costs

Physician-Patient Alliance for Health & Safety nominates the respiratory care department of St. Joseph’s/Candler Hospitals in Savannah, Georgia for RT Magazine’s “Best of Care” award. Read More

Researchers calculate that hospitals spend between $2.7 million and $13.5 million on malpractice litigation.
Opioid Safety, Respiratory Compromise

5 Resources on the Costs of Adverse Events

by Sean Power

Patient safety advocates at hospitals sometimes face roadblocks when introducing new safety measures. One approach to overcome these obstacles involves looking at the financial costs absorbed when things go wrong.

An ounce of prevention is worth a pound of cure. This article explores the legal costs associated with adverse events and ways to minimize unnecessary expenses. Read More

Opioid Safety, Respiratory Compromise

Case Study in How to Eliminate Adverse Events, Improve Patient Safety, and Reduce Healthcare Costs

St. Joseph’s/Candler Hospitals reduced opioid-related events with patient-controlled analgesia (PCA) pumps. The hospitals are “error-free” since using “smart” PCA pumps with integrated capnography.

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

St. Joseph’s/Candler Hospitals (SJ/C) in Savannah, Georgia, are two of the oldest continuously operating hospitals in the US. About 10 years ago, SJ/C had three opioid-related events with patient-controlled analgesia (PCA) with serious outcomes over a two-year period.

Fortunately, none of these adverse events resulted in deaths, says Carolyn Williams, RPh, Medication Safety Specialist at SJ/C.

Since using “smart” PCA pumps with integrated capnography, SJ/C has been “error-free”. Read More