Alarm Fatigue, Patient Monitoring, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Feb 13, 2015)

We hope there are no superstitious people reading on this Friday the 13th.

Let’s get to it. Must Reads from the past week.

New Stroke VTE Safety Recommendations Prevent Blood Clots In Stroke Patients

Earlier this week, PPAHS announced the release of safety recommendations targeting the prevention of venous thromboembolism (VTE) in stroke patients.

Stroke is a leading cause of death and disability in the U.S., with 800,000 cases occurring each year.

Download the Stroke VTE Safety Recommendations here.

Four Reasons to Expand Capnography

Advance Healthcare Network for Respiratory Care & Sleep Medicine published an article outlining why health systems should expand the use of capnography.

  1. Enhancing patient safety
  2. Newer guidelines and checklists to monitor patients
  3. Improved outcomes
  4. Improved consistency of care.

Citing experts like Dr. Bhavini Kodali, Dr. Frank Overdyk (who sits on the PPAHS board of advisors)—and referencing the PPAHS PCA Safety Checklist—the article is a good summary of why capnography use should be expanded outside the OR.

Health Illiteracy a Root Cause of Medical Error

In 2004, The Institute of Medicine (IOM) released a report, saying that that 90 million people in America have difficulty understanding and using health information.

On a personal blog, Thomas Sharon, RN, MPH, recently shared his perspective on patients who lacked basic health literacy after encountering thousands of patients in the home environment over two decades. It is always good to get perspectives from the field, so we thought we would highlight this blog article.

Both the IOM report brief and Mr. Sharon’s article may be worth reading.

Patient Satisfaction Scores Not Affected by Amount of Opioids Given in Emergency Room

Pain Medicine News reports that researchers at two New England hospitals performed a retrospective analysis of medical records and completed surveys of nearly 5,000 patients seen in the ER department.

The researchers asked whether the amount of opioids administered in the ER were associated with Press Ganey scores, a common tool to measure patient satisfaction, according to the authors. The answer, they found: no.

According to Chris Pasero, pain management educator and clinical consultant:

“What’s happening nation-wide is a focus on opioid-only treatment plans. This is problematic.”

The new research may strengthen the case for multi-modal pain management programs.

Can Turning Down Alarms Improve Patient Safety?

A study from one of the intensive care units at Abbott Northwestern Hospital looked at whether changing default settings of pulse-rate alarms could improve patient safety.

By changing the thresholds, the study found that the number of pulse rate alarms dropped 76 percent within six months without any emergencies being missed.

Researchers at Dartmouth-Hitchcock Medical Center likewise observed benefits from revising default alarm settings.

Thanks, @AAMIFoundation and others, for tweeting about the Abbott story.

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