News

News

New Joint Commission Alert Addresses Medical Device Alarm Safety in Hospitals

 

The constant beeping of alarms and an overabundance of information transmitted by medical devices such as ventilators, blood pressure monitors and ECG (electrocardiogram) machines is creating “alarm fatigue” that puts hospital patients at serious risk, according to a Sentinel Event Alert issued by The Joint Commission in April.

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MITSS: Supporting Patients and Families for More than a Decade

MITSS: Supporting Patients and Families for More than a Decade

 

Over the past decade, the patient safety movement has focused much of its attention on prevention, and rightly so. Still, even in the safest of systems, things can, and often do, go wrong. Of late, much has been published regarding the “second victim,” a term used to describe healthcare providers finding themselves on the sharp end of an error or adverse event. Yet, little has been documented about the emotional impact on patients and their families and the need for support following these events.

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Addressing Alarm Problems in the Emergency Department

Addressing Alarm Problems in the Emergency Department

 

Stand for a few moments in the middle of your emergency department (ED) to just listen and observe. How many alarms do you hear? Can you distinguish where each alarm is coming from and whether it’s a physiologic monitor or ventilator or infusion pump alarm? Does each alarm connote the level of urgency needed for the nurse to respond promptly and appropriately? Do you observe nurses scurrying to respond? Or do the alarms perpetuate while no one responds?

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Health IT & Quality: American Autos Circa 1970 and Healthcare

Health IT & Quality

American Autos Circa 1970 and Healthcare

 

The Ford Pinto was a really terrible car. The gas tank was positioned such that, in a collision, protruding differential bolts would puncture the tank, leading to frequent car fires. This defect led to the death of more than 27 people and many others maimed. Other cars representative of this defect-filled era of U.S. auto manufacture include the Ford Fairmont, AMC Gremlin, and Chevy Vega. Cars made in the United States in the 1970s and 1980s were poorly designed, cheaply assembled, and reliably unreliable.

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Ochsner Baton Rouge Boosts Patient Safety with Expanded Use of Capnography

Ochsner Medical Center –Baton Rouge recently expanded its use of capnography to monitor patients using pain medication through patient controlled analgesia (PCA) to strengthen patient safety measures. Capnography evaluates how effectively patients are breathing by measuring exhaled carbon dioxide, alerting medical caregivers when life-threatening respiratory depression occurs.

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Change of Scenery: Just What the Doctor Ordered

Change of Scenery: Just What the Doctor Ordered

 

Being hospitalized should not necessarily preclude a patient from going outdoors independently, that is, without the assistance or supervision of a healthcare staff member. Nonetheless, reconciling the need to ensure patient safety with the patient’s desire to enjoy the therapeutic benefit of being off the unit and outdoors can create conflict for patients and healthcare providers.

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AHRQ: CUSP – Scaling Up a Safety Framework

AHRQ

CUSP: Scaling Up a Safety Framework

 

In the 13 years since the Institute of Medicine (IOM) issued its clarion call exposing major deficiencies in U.S. healthcare (2000), improving patient safety has been a foremost goal within our system. Providers, purchasers, consumers, payers, regulators, and other stakeholders have worked tirelessly together to formulate strategies to reduce needless harms (including needless deaths) resulting from care.

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Diagnostic Error: Safe and Effective Communication to Prevent Diagnostic Errors

Diagnostic errors (i.e., diagnoses that are delayed, wrong, or missed) are increasingly recognized as a patient safety concern in ambulatory care (Singh & Graber, 2010). A recent report from the American Medical Association (AMA) Center for Patient Safety (Lorincz et al., 2011) highlighted the importance of diagnostic error and the critical need for future research on this topic.

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ISMP: Drawn Curtains, Muted Alarms, and Diverted Attention: Tragedy in the PACU

ISMP

Drawn Curtains, Muted Alarms, and Diverted Attention: Tragedy in the PACU

 

Last April, a 17-year-old girl died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentaNYL in the postanesthesia care unit (PACU). The case made headline news again recently when a civil lawsuit filed by the teen’s parents was resolved. While it is too late to reverse the tragic outcome of this case, we call upon all hospitals and outpatient surgery centers to learn from the event and take action to prevent a similar tragedy in their facilities.

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