Patient Safety, Respiratory Compromise

“Good” Hospitals Require Real Leaders

The following is an excerpt of an article written by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety). It first appeared on Healthcare Business Today on April 9, 2017. To read the full article, please click here.

As the Executive Director of the Physician-Patient Alliance for Health & Safety, a non-profit whose mission is the improvement of patient safety, I am often asked how to tell a “good” hospital (i.e. patient safe) from a “bad” hospital (i.e. unsafe).

In thinking about “good” and “bad” hospital leadership, I am reminded of two discussions I had with hospital leaders – which leaders’ hospital would you rather be a patient at or, if you are a clinician, work at?

I spoke with the CEO of a hospital, who was dealing with the family of a child that had died within the hospital from opioid-induced respiratory depression. His clinicians had not employed continuous electronic monitoring with pulse oximetry for oxygenation or with capnography for adequacy of ventilation. Read More

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 (March 4, 2017)

This week in #patientsafety, we shared an article on opioids in dentistry by Bradley Truax, MD. Outpatient Surgery covered our position statement on patient ambulation. From around the web, NPR wrote about dentists working to use fewer opioids, a hospital reduced nuisance alarms by 30%, and The Joint Commission issued a new Sentinel Event Alert on developing a culture of safety.


Patient Safety Tip of the Week: Dental Patient Safety. As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted an article on dental patient safety (with permission).

Push to Make Ambulation a Key Patient Recovery Metric. Outpatient Surgery covered our position statement on patient ambulation.

From Around the Web:

Dentists Work To Ease Patients’ Pain With Fewer Opioids. Dr. Joel Funari performs some 300 tooth extractions annually at his private practice in Devon, Pa. He’s part of a group of dentists reassessing opioid prescribing guidelines in the state.

Hospital’s program reduces nuisance alarms 30 percent. Nurses at Palomar Health in California were part of a study designed to reduce alarm fatigue. The health system decreased its alarms by nearly 30 percent.

Sentinel Event Alert 57: The essential role of leadership in developing a safety culture. “Competent and thoughtful leaders contribute to improvements in safety and organizational culture,” says The Joint Commission.

Opioid Safety, Respiratory Compromise

Tools and Recommendations for Assessing the Risk of Over-Sedation and Respiratory Depression

Although there are benefits to the use of opioids for the management of pain, particularly with patients post-operatively, there are risks of over-sedation and respiratory depression, as The Joint Commission cautions in its Sentinel Event Alert “Safe use of opioids in hospitals”:

While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.

Assessing which patients are at risk of developing opioid-induced respiratory depression (OIRD) would be of benefit, as treatments could be altered or tailored to the particular patient to reduce the risk of opioid-related adverse events.

The Michigan Opioid Safety Score (MOSS) was “developed to incorporate patient risk, respiratory rate, and sedation into one bedside score that could be used to improve patient safety during inpatient opioid therapy. Scoring is based on a summation of risk data with objective bedside measures of over-sedation trumping a patient’s subjective reports of pain.” Read More

Alarm Fatigue, Patient Safety

How One Healthcare System Used Two Interventions to Tackle Alarm Fatigue

By Sean Power
November 11, 2015

How many telemetry alarms are generated in a single month by two hospitals, 716 beds, 36,386 admissions, 93,634 visits to the emergency department, 3,418 births, 453 open-heart surgeries, and 11,688 surgical procedures?

Over a quarter million, according to Kevin Smith, BSN, RN, CNML, CVRN-BC, Director II Cardiac Telemetry Services at NCH Healthcare System in Naples, Florida, in a presentation shared at the Association for the Advancement of Medical Instrumentation Foundation’s (AAMI) Patient Safety Seminar.
Read More

Respiratory Compromise

Could Intraoperative Handoff Checklists Prevent Medical Errors?

by Sean Power

The Joint Commission estimates that 80 percent of medical errors involve miscommunication between caregivers during the handoff between medical providers.

New research published in Anesthesia & Analgesia suggests that an electronic checklist may help, especially during intraoperative transfers of care. Read More

Alarm Fatigue, Blood Clots, Must Reads, Respiratory Compromise

Weekly Must Reads in Patient Safety (Jan 16, 2015)

Achieving patient safety is the watchword for this week’s Must Reads.

2015 National Patient Safety Goals

The Joint Commission’s 2015 National Patient Safety Goals were released. Although TJC says that it has “no new Goals for 2015”, it is probably a good presentation for all healthcare facilities to look at to make sure they are meeting these objectives. Read More

Alarm Fatigue, Must Reads

Weekly Must Reads in Patient Safety (Dec 5, 2014)

The Agency for Healthcare Research and Quality (AHRQ) estimates that 1.3 million fewer patients were harmed in U.S. hospitals from 2010 to 2013. AHRQ attributes this to “focused and widespread efforts to reduce surgical-site infections, adverse drug events and other preventable incidents.” Read More

Alarm Fatigue, Must Reads, Respiratory Compromise

Weekly Must Reads in Patient Safety (Nov 28, 2014)

Happy Thanksgiving!

Do We Need to Start a Revolution? – This is the question asked by Fred N. Pelzman, MD, who writes:

Over and over again, we were told about the sorry state of the U.S. healthcare system, how we are first in cost and last in quality, and there’s something inherently wrong with the way “we” take care of people in this country.

Read More