Patient Monitoring, Patient Safety

Podcast on Continuous Electronic Monitoring

In this podcast AAMI Foundation’s Healthcare Technology Safety Institute, Frank Overdyk, MD, professor of anesthesiology at Hofstra North Shore-LIJ School of Medicine and executive director for research at North American Partners in Anesthesia, and Tim Vanderveen, vice president of CareFusion’s Center for Safety and Clinical Excellence, make the case for continuous electronic monitoring and address the challenges stakeholders face in trying to bring about this change.

Dr. Overdyk is an advisor to the Physician-Patient Alliance for Health & Safety and, with Mr. Vanderveen, is a co-chair of the National Coalition to Promote Continuous Monitoring of Patients on Opioids.

opioids partner

To listen to the podcast, please see “Episode 7” by clicking here.

Patient Monitoring, Patient Safety

Outpatient Centers vs. Hospitals: Lessons Learned from the Death of Joan Rivers

The headline of a recent Washington Post article reads “Joan Rivers’s death spurs new look at outpatient centers”.

Although ABC News reports that the outpatient center that treated Joan Rivers is losing both Medicare certification and accreditation from the American Association for Accreditation of Ambulatory Surgery Facilities (AAASF), Kenneth P. Rothfield, MD, MBA, CPE, CPPS (System Vice President, Chief Medical Officer, Saint Vincent’s Healthcare, Ascension Health) points out that the question is not whether outpatient centers are better or worse than hospitals, but whether the facility is properly equipped and personnel adequately trained:

I don’t think it’s the venue that’s the most important thing,” said Rothfield, a member of the board [of advisors] of the Physician-Patient Alliance for Health & Safety, a nonprofit group. “ASCs [ambulatory surgery centers] traditionally have done simpler procedures in healthy patients,” while hospitals have routinely dealt with a broader and sicker — mix of people. Hospitals, he said, are more likely to be fully equipped and to have staff members with greater experience handling emergencies. “Unless you have drilled for it, and trained for it, it can be hard to pull off.

In addition, the medical standards of care upheld by healthcare facilities may differ. Although hospitals typically seek accreditation from The Joint Commission, ambulatory centers can receive accreditation from a variety of organizations. For example, the AAASF accredits ambulatory surgery facilities like the one where Joan Rivers underwent her medical procedure.

How might these standards specifically differ?

In the article “Medical standards of care and the Joan Rivers death,” differing standards of monitoring patients receiving opioids are discussed:

What is instructive in terms of gained knowledge in the Joan Rivers’ death are the differing patient safety measures in place by the application of standards when a sedative is delivered to the patient.

The AAAASF standard would have monitored for oxygenation by pulse oximeter, which measures the amount of oxygen in blood. Measuring oxygenation provides a very late indicator of hypoventilation, or ineffective breathing. In other words, there would have been a delay in the detection of low blood oxygenation by pulse oximeter.

The ASA [American Society of Anesthesiologists] standards provide an extra level of patient safety by requiring that the adequacy of ventilation be monitored in addition to oxygenation. The ASA standards therefore call for the “continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide”.

Even in hospitals, however, multiple standards of care may exist. Although anesthesiologists, the recognized experts in providing safe sedation, are required to monitor adequacy of breathing by measuring exhaled carbon dioxide, non-anesthesiologists such as gastroenterologists, surgeons, and radiologists are not required to provide this extra measure of safety. For example, American Society for Gastrointestinal Endoscopy “Guidelines for safety in the gastrointestinal endoscopy unit” does not require monitoring for adequacy of ventilation by Capnography, as required by the ASA.

So, how can patients decide on which healthcare facility to undergo a surgical procedure?

The Physician-Patient Alliance for Health & Safety offers four simple points to keep in mind:

  1. Even “minor” procedures can have major risks and hidden harm

The ASA reminds us that although “anesthesia is safer than ever before, every person scheduled for a procedure or surgery must have a serious conversation with their physician anesthesiologist about their anesthesia care delivery plan ahead of time … Even ‘minor procedures’ are not risk-free.”

  1. Ask questions to fully understand the medical procedure you are to undergo

Physicians must communicate and patients need to fully understand the full nature of the medical procedure. It is often helpful to have a family member, friend or significant other with you to check if you asked all your questions and another set of “ears” to listen to what is being told or explained to you.

U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) believe “clinicians and patients [need] to engage in effective two-way communication to ensure safer care and better health outcomes.”

This type of patient engagement and education should be told to the patient, and then to ensure an adequate level of understanding the clinician should ask for verbal or written feedback from the patient..This validates the patient’s understanding and is termed ”readback feedback”.

AHRQ encourages patients to ask their medical providers questions, as illustrated in this humorous video which shows how patients ask many questions everywhere (such as in a restaurant) but not in the doctor’s office (please click on the image to view the video):

AHRQ Restaurant Ad

AHRQ Restaurant Ad

  1. Make sure you are monitored electronically, with both pulse oximetry and capnography, if you are to receive sedation, opioids or anesthesia

Even “routine” procedures may entail the use of a sedative, opioids, or anesthesia, additionally there maybe use of a combination of more than one of these medications. The endoscopic procedure performed on Ms. Rivers, which would have likely involved insertion of a large scope into her mouth, is a simple and common procedure, but, as noted by Dr. Karen Siebert, “uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.” The type of sedation given can be Monitored Anesthesia Care (MAC) or I.V. Conscious sedation.

The Anesthesia Patient Safety Foundation (APSF) believes that clinically significant drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.

Continually evaluating and monitoring respiratory and circulatory status prior to, during, and following the procedure is essential. As a recent video released by the APSF demonstrates continuous electronic monitoring of oxygenation (the adequacy of oxygen in the blood) with pulse oximetry and ventilation (adequacy of breathing) with capnography, These combined with traditional in-depth nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment and distress.

Virtually all proceduralists use pulse oximetry to measure blood oxygen levels as a standard of practice. Assessing ventilation is another issue. The ability to tell by simple observation if a patient is breathing adequately or not during a procedure can be tricky. Surprisingly, standards for capnography monitoring are not the same for all medical specialists.

Anesthesiologists are required by the ASA to measure the adequacy of ventilation using capnography (a device which measures exhaled carbon dioxide) to provide breath-by-breath monitoring. Other specialists, such as gastroenterologists and dentists, are not required to use this technology. Without capnography, several critical minutes can elapse after a patient stops breathing before medical professionals are alerted to the situation. Unfortunately, by this time, a serious problem or even a cardiac arrest may occur.

  1. Equipment and resources at an outpatient clinic may be different than at a hospital

If your procedure is scheduled at an outpatient clinic be sure to ask about available emergency equipment at the clinic. Just because your procedure is scheduled in an outpatient type of clinic, do not take this lightly and ask about code cart availability, emergency drugs to manage your condition and any adverse events, and lastly trained clinicians available and knowledgeable about handling potential life threatening emergencies.

As Dr. Rothfield cautions, the venue does not necessarily dictate better patient safety and health outcomes. Ensuring that the facility is properly equipped, its personnel adequately trained and whether its patients receiving opioids are continuously monitored – these are some key questions.

Patient Monitoring, Patient Safety

What Did Joan Rivers Die From?

at the Heller Awards 2013, Beverly Hilton Hotel, Beverly Hills, CA 09-19-13

Reports WomensHealth:

As more details emerge about Joan Riversdeath, one thing is clear: It could have been prevented. When it comes to elective surgery, even famous people who have access to the best – arent immune to complications

One lesson we can learn from this tragedy is to think more than twice before going through any non-essential surgery, says Dr. Marc Leavey, primary care specialist at Mercy Medical Center. In his career, he has seen people want unnecessary surgery, cosmetic or otherwise. After fighting to have it, they end up with untoward complications from disability to death. Surgery is surgery, whether ‘major’ or ‘minor,and should not be entered into lightly,he says.

To read the full article and WomensHealth’s citation of the Physician-Patient Alliance for Health & Safety’s four ways in which patients can learn from Rivers’ experience, please click here.

Patient Monitoring, Patient Safety

Could Intraoperative Handoff Checklists Prevent Medical Errors?

by Sean Power
February 17, 2015

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.

Handoffs can be high-risk error-prone patient care episodes. The risk is rooted in several possible causes: inaccurate information; lack of consistency, organization, and standardization in how information is communicated; distractions and information overload, to name a few.

A team of researchers at Massachusetts General Hospital and Harvard Medical School led by Aalok V. Agarwala, MD, MBA, compared relay and retention of critical patient information between the outgoing and incoming anesthesiologist before and after introducing a checklist.

The goal of the checklist developed by the researchers was to improve the quality of the handoff process along with care.

For handoffs in which the checklist was used, the authors observed statistically significant improvements in the relay of two main categories of information: intraoperative medication and fluid balance.

This improvement was associated with a larger percentage of anesthesiologists being able to recall patient information after the handoff took place.

Key Information Relayed at Handoff

The electronic handoff checklist consisted of fields containing important patient data:

  • Demographics including age, weight, and body mass index
  • Past medical history and medications
  • Airway
  • Access
  • Fluids
  • Perioperative medications
  • Antibiotics
  • Intraoperative concerns
  • Postoperative plan
  • Introduction of incoming anesthesia provider

Intraoperative Handoff Checklist

Where possible, fields were pre-populated with data collected from an anesthesia information management system. Checkboxes were used so that the outgoing anesthesiologist could verify the accuracy of information at handoff.

The team observed 30 handoffs without the checklist and 39 with it. They looked for changes in how frequently communication was relayed and how effectively this knowledge was retained.

Improvements in Information Relay and Retention

The researchers observed improvements in relay in several areas:

  • Administration of vasopressors and antiemetics
  • Estimated blood loss and urine output
  • Communication about potential areas of concern
  • Postoperative planning, and
  • Introduction of the relieving anesthesiologist to the operating team.

The checklist improved knowledge retention, as well. Specifically, the relieving anesthesiologist more frequently knew the antibiotic and muscle relaxant used, as well as the amount of fluid administered.

Clinicians who used the checklist in at least 67 percent of their handoffs reported higher satisfaction with quality of communication at handoff.

Perhaps most impressive (or alarming, depending on how you look at it): the checklist improved how frequently the incoming anesthesiologist was introduced to the rest of the operative team, from 3 percent of the time to 51 percent of the time.

Post-Handoff Assessment: Satisfaction with Handoff

As part of the research, the authors assessed the relieving anesthesiologist’s satisfaction with the information conveyed and retention of information transferred.

Post-Handoff Assessment

Satisfaction levels trended toward improvement in perceived quality of communication.

This trend did not reach statistical significance, although it held true across all provider groups (clinicians, faculty anesthesiologists, trainees, and CRNAs).

There was, however, a significant reduction in the perception that the handoff was rushed when the checklist was used, even though the duration of handoffs performed with and without the checklist was not significantly different.

Handoff Assessment Table

Voluntary Adoption

In January 2013 (three months after the checklist’s introduction in October 2012), the checklist was used in 60 percent of intraoperative handoffs.

By June, that figure had reached 74 percent.

Percentage Checklist Usage by Month

Could electronic intraoperative handoff checklists improve patient safety?

These findings point to yes—and the increase in voluntary uptake seems to suggest that operating teams might think so, too.

What do you think? Leave your answer and thoughts below.

Capnography, Patient Monitoring, Patient Safety

Two Practices to Adopt After Pediatric Opioid Trial Halted

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

With more than 500,000 pediatric tonsillectomies performed each year in the United States, removal of tonsils is one of the most common surgeries performed on children. According to the American Academy of Otolaryngology Head and Neck Surgery, tonsillectomy is performed 20 percent for infection and 80 percent for obstructive sleep apnea.


(for more on opioids and patent safety, please see click on the picture)

Children undergoing tonsillectomy with or without adenoidectomy are routinely given morphine to manage their pain following surgery. This standard practice of using morphine is being called into question by a recent study conducted by the Motherisk Program at The Hospital for Sick Children (SickKids) and by McMaster University and McMaster Children’s Hospital.

The study results were published in the January 2015 issue of Pediatrics, after the study’s Drug Safety Monitoring Board halted the trial following an interim analysis which strongly demonstrated a high degree of risk of respiratory compromise associated with the use of morphine. One child even suffered a life-threatening adverse drug reaction including oxygen desaturation after being treated with morphine.

What lessons can be learned from this trial?

1. Opioids Should be Prescribed Cautiously, not Routinely

Study co-author Doron Sommer, MD (Clinical Professor of Surgery, McMaster’s Michael G. DeGroote School of Medicine; surgeon, McMaster Children’s Hospital) explained:

These results should prompt clinicians to re-evaluate their post-tonsillectomy pain treatment regimen. Due to the unpredictable respiratory side-effects of morphine, its use as a first-line treatment with current dosage ranges should be discontinued for outpatient tonsillectomy.

The study found that using Ibuprofen in combination with acetaminophen provides safe and effective analgesia in children. As fellow researcher Gideon Koren, MD, FRCPC (Director, Motherisk Program; Senior Scientist, SickKids) said,

The good news is that we now have evidence that indicates ibuprofen is safe for these kids, and is just as effective in controlling their pain, so there’s a good alternative available for clinicians to prescribe.

2If Opioids are Prescribed, Patients Should be Monitored

The Joint Commission cautions that an opioid analgesic like morphine, although usually safe, may be associated with adverse effects, the most serious being respiratory depression preceded by sedation.

EurekAlert! reports that at “both SickKids and McMaster Children’s Hospital, the use of morphine for post-operative pain from pediatric tonsillectomy is reserved for exceptional cases where it is deemed necessary and safe with appropriate monitoring.”

What should the “appropriate monitoring” be?

The National Coalition to Promote Continuous Monitoring of Patients on Opioids recently had its inaugural meeting. The goal of the Coalition is “to establish the business case, demonstrating strong financial justification and improved patient outcomes, and to educate and encourage hospitals to adopt continuous monitoring for all patients on opioids.”

Co-conveners of the Coalition’s inaugural meeting included The Joint Commission, The Anesthesia Patient Safety Foundation, the Institute for Safe Medication Practices, the National Patient Safety Foundation, and the VA National Center for Patient Safety.

The Physician-Patient Alliance for Health & Safety, also a co-convener, recently issued this statement in support of the objectives of the National Coalition to Promote Continuous Monitoring of Patients on Opioids:

To improve patient safety and save patients’ lives, we recommend adopting continuous respiratory monitoring of all patients receiving opioids with pulse oximetry for oxygenation and with capnography for adequacy of ventilation to improve timely recognition of respiratory depression, decompensation or clinical deterioration.

Concludes Gina Pugliese, RN, MS (Vice president, Premier Safety Institute):

We need to promote the safe and responsible use of opioids. One place to start is with common procedures like tonsillectomies. The Motherisk Program shows us that opioids can be safely and effectively be replaced with non-opioid alternatives. That said, if opioids must be used, to prevent respiratory depression and improve safety, patients receiving opioids should be continuously electronically monitored.


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

Weekly Must Reads in Patient Safety (Jan 23, 2015)

Alarms! Alarms! Alarms! … and a family seeks answers to death at a VA hospital.

But, before we get to the serious news … a little humor …

Alarm joke

(Source: The Happy Hospitalist)

The Alarm vs. Alert Conundrum

Sue Montgomery, RN, BSN, CHPN reminds us about the difference between “alarms” and “alerts”:

The terms “alarm” and “alert” are often used interchangeably, but they’re not the same thing. Alarms usually indicate a potentially life-threatening situation requiring an immediate response and are regulated by the FDA as part of the agency’s oversight of medical devices. By contrast, alerts are usually associated with non-medical devices and don’t indicate an immediate crisis. Some examples include nurse call systems and message notifications.

Alerts might be less critical than alarms, which is why they’re not regulated in the same way, but they both add to the general cacophony nurses face every day. Several studies have found that it’s difficult for most people to differentiate more than six different alarm sounds, but the American Association of Critical Care Nurses says the average ICU nurse must cope with more than three dozen sounds. It’s no wonder that alarm overload or alarm fatigue is becoming epidemic.

Alarm Fatigue and Telehealth

According to ECRI, alarm fatigue-reducing technologies and telehealth are among the top 10 technology tools hospital executives should watch for in 2015.

ECRI Institute’s 2015 Top 10 Hospital C-Suite Watch List is available as a free public service. It seeks to provide “answers [to] key questions on new and emerging health technologies that potentially provide new ways to treat patients, improve care, and reduce costs.”

Thanks to @gnayyar, @IVCiLLC, and @iHealthBlog for tweeting about this!

Man’s Family Seeks Answers After His Death at a VA Hospital

As reported by the Post Register in Idaho Falls, Idaho (note: access to the full article is only for Post Register subscribers), Richard Palmer was the victim of over-sedation after undergoing routine surgery:

Richard Palmer, awoke June 11 feeling well after undergoing routine surgery. He called his daughter at 3:30 p.m. to check in with her following the procedure.

After the operation, a catheter was placed in Palmer’s femoral nerve to administer a local anesthetic — bupivacaine — to manage his pain.

The VA later learned the pump, which regulates how fast the medicine is released, was not assembled properly, leading to the free-flow of the anesthetic for 11 minutes.

According to the medical examiner’s report, Palmer reported feeling anxious and having a tingling sensation in his feet. Then he had a seizure.

At 5:15 p.m., a blood test showed Palmer had 14 times more bupivacaine in his system than he was supposed to. At 7:29 p.m., he was pronounced dead.

Editor’s note: Use of the PCA Safety Checklist may have averted this tragedy. One of the steps to be followed before initiating, refilling, or programming change is to have two healthcare providers independently verify:

  • patient’s identification
  • all patient allergies appear prominently on medication administration record (MAR)
  • drug selection and concentration confirmed as that which was prescribed
  • any necessary dose adjustments completed
  • PCA pump settings
  • line attachment to patient and tubing insertion into pump

Sounds simple – but simple could have saved a life.

Patient Monitoring, Patient Safety

Physician-Patient Alliance Recommends Continuous Respiratory Monitoring of All Patients Receiving Opioids

The Physician-Patient Alliance for Health & Safety today issued the following statement encouraging the continuous electronic monitoring of all patients receiving opioids:

To improve patient safety and save patients’ lives, we recommend adopting continuous respiratory monitoring of all patients receiving opioids with pulse oximetry for oxygenation and with capnography for adequacy of ventilation to improve timely recognition of respiratory depression, decompensation or clinical deterioration.

In Amanda's Memory, Always Monitor

The Centers for Medicare & Medicaid Services (CMS) issued on March 14, 2014 revised guidance, “Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids”.

The CMS guidance recommends “at a minimum” that hospitals “have adequate provisions for immediate post-operative care, to emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.”

In addition and more importantly, the CMS guidance necessitates monitoring for all patients receiving opioids when in hospital:

Narcotic medications, such as opioids, are often used to control pain but also have a sedating effect. Patients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. Timely assessment and appropriate monitoring is essential in all hospital settings in which opioids are administered, to permit intervention to counteract respiratory depression should it occur.

“In issuing this statement,” explains Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), “we are especially reminded of Amanda Abbiehl, Leah Coufal, John LaChance, and countless others who may still be alive today had they been continuous electronically monitored.”

Physician-Patient Alliance released these and other stories of patients who suffered opioid-induced respiratory depression at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids. For a full copy of all of the stories shared with the meeting’s attendees, please click here.

The CMS guidance provides increased vigilance to patients receiving opioids, particularly those patients receiving opioids postoperatively. CMS explains the reason behind the issue for this guidance:

 Each year, serious adverse events, including fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid-induced respiratory depression has resulted in patient deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient’s respiration rate, oxygen and sedation levels. Hospital patients on IV opioids may be placed in units where vital signs and other monitoring typically is not performed as frequently as in post-anesthesia recovery or intensive care units, increasing the risk that patients may develop respiratory compromise that is not immediately recognized and treated.

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

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.

The Joint Commission 2015 National Patient Safety Goals

The first two articles may help achieve better patient safety. The latter two were shared by the Twitter health care and patient safety community – many thanks for making these Must Reads a collaborative effort.

Using Capnography to Effectively Measure How Patients Are Breathing

The Journal of Clinical Engineering discusses how Glendale Adventist Medical Center (Glendale, CA) is improving patient safety by using capnography to monitor patients during moderate sedation.

Michael O’Connor (Director of Respiratory Therapy, Glendale Adventist Medical Center) explains:

Glendale Adventist Medical Center is committed to providing the highest quality of care. Our widespread use of capnography to monitor the breathing of patients who are being sedated is in line with the latest requirements from the ASA [American Society of Anesthesiologists] and underscores our dedication to patient safety.

New Toolkit to Reduce Alarm Fatigue

The National Association of Clinical Nurse Specialists (NACNS) released a toolkit “to facilitate CNSs’ efforts to facilitate appropriate alarm management and help staff implement strategies to ensure alarm safety”.

“As leaders in ensuring evidence-based care, CNSs have an important role to play in reducing the potentially dangerous and deadly problem of alarm fatigue,” said NACNS 2014 President Les Rodriguez, MSN, MPH, RN, ACNS-BC, APRN. “Our toolkit was developed by a group of national experts whom NACNS convened to address this important issue and provide resources that will help nurses across the country combat this problem. It is intended to help guide their efforts to improve patient safety and quality of care. The toolkit includes everything a CNS needs to work collaboratively with an interprofessional team to assess the clinical environment, and then develop implement and evaluate appropriate interventions.”

New Rules to Curb ‘Epidemic’ of Cesarean Births in Brazil

From the article:

Brazil has unveiled new rules aimed at stemming the South American nation’s “epidemic of cesareans” and promoting natural births among private health care providers.

Health Minister Arthur Chioro called Brazil’s obsession with cesareans, which account for more than eight out of 10 births handled by private health providers, a “public health problem.”

Hat tip to @MinasIntl for sharing this article on Twitter. Dr. Peter Cherouny said in a past webinar “no patients are low risk” when it comes to cesarean delivery and venous thromboembolism.

Recent Research About Nursing, December 2014

“After a while, alarms stop being so alarming.”


Read the article here.

Hat tip to @comunikator and others for sharing this article on Twitter.

Patient Safety

Three Steps to Limiting Liability to Facility-Acquired Pressure Ulcers

The Risk Management Quarterly, the peer-reviewed journal for The Association for Healthcare Risk Management recently published in its Risk Management Quarterly Journal-Volume I 2015 Edition the article by Scott Buchholz, Esq. (Dummit, Buchholz & Trapp) and Michael Wong, JD, (executive director, Physician-Patient Alliance for Health & Safety) three practical tips for healthcare facilities to improve patient safety (i.e. follow protocols) and increase patient satisfaction (i.e. communicate effectively with patients).

To read the article in its entirety, please RMQ Article-Buchholz & Wong.

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

Weekly Must Reads in Patient Safety (Jan 9, 2015)

The Physician-Patient Alliance for Health & Safety wishes you and your loved ones a Happy and SAFE New Year!

Safety first

We particularly emphasize SAFE, because the latest news on patient safety shows that there is a lot work yet to be done … or perhaps we haven’t started? …

No Improvement in Patient Safety in Last 15 Years

HC Pro’s Patient Safety Monitor reports that, according to health experts testifying to a Senate subcommittee, that there has been no improvement in patient safety in the last 15 years:

If the truth hurts, any patient safety advocates that tuned into the Senate subcommittee hearing on patient safety were probably cringing.

No one minced words at the hearing for the Subcommittee on Primary Health and Aging on July 17, as health experts testified that patient safety has remained largely stagnant for the last 15 years. In some respects, it’s worse, failing to prevent as many as 400,000 patient deaths each year, four times more than estimates from the Institute of Medicine (IOM) in 1999.

Penalties for Hospital-Acquired Conditions

Validating this sober assessment, more than 700 hospitals “will see their total Medicare payments docked by 1 percent in fiscal 2015 as part of the first year of a federal penalty program aimed at reducing preventable harm and improving patient safety”, reports Modern Healthcare. Hospital-acquired conditions included pressure ulcers and pulmonary embolisms.

Although one would think that teaching hospitals would be the vanguard of innovation and safety, hospitals penalized include many well-known teaching hospitals – including Intermountain Medical Center, Ronald Reagan UCLA Medical Center, the Cleveland Clinic, Geisinger Medical Center, Brigham and Women’s Hospital, NYU Langone Medical Center and Northwestern Memorial Hospital.

That said, if you have a choice of hospitals, data from AHRQ’s Healthcare Cost and Utilization Project suggests that being admitted at a hospital in the West is preferable to going to one in the South:

Rates of potentially preventable hospitalizations in the United States declined 14 percent from 2005 to 2011, but rates varied widely by geographic region, according to a new statistical brief from AHRQ. Potentially preventable hospitalizations are admissions for certain acute illnesses or worsening chronic conditions that may have been avoided with higher-quality outpatient treatment and disease management. Data from AHRQ’s Healthcare Cost and Utilization Project showed that rates of potentially preventable hospitalizations in 2011 were lowest in the West (at 1,220 discharges per 100,000 population) and highest in the South (at 1,845 discharges per 100,000). Hospitals in the South had a 17.2 percent higher rate of potentially preventable hospitalizations than the overall national rate in 2005, but by 2011 it was reduced to 10.5 percent higher than the national rate.

Pregnancy-related deaths on the rise in the US

Moreover, a new study has found that even something as common as childbirth may no longer be safe:

A century ago, deaths during pregnancy or childbirth were not uncommon; however, advances in prenatal care have made great strides in increasing the likelihood of a good outcome for both mothers and their offspring. However, a new study has reported that pregnancy-related mortality has increased in recent years in the United States.

The Answer

Maureen F. Cooney, DNP, FNP, BC (Westchester Medical Center, Valhalla, NY), who spoke at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids, says the answer (at least for patients receiving opioids) is continuous monitoring. However, she reminds us that technology alone is not the answer. We also need trained bedside nurses to keep patients safe from opioids and the dangers of high-alert medications:

Continuous monitoring of patients receiving opioid therapy to prevent opioid-related respiratory depression certainly offers the hope of reducing devastating outcomes from our well-intended efforts to assure patient comfort. However, in this climate of rapid, high-tech, outcomes-driven healthcare, it is essential to keep in mind the end user—particularly the bedside nurse.

Thanks @HIEcentral for tweeting about this!