Archive for April, 2012|Monthly archive page

Realtime adverse event information

In adverse events, Patient Safety on April 24, 2012 at 7:55 pm

Here is a sample of the information at your fingertips on Adverse

FDA warns Fentanyl patch poses risk to children. 

On April 18, 2012, the FDA issued a safety alert to warn about the dangers posed to children from the accidental exposure to fentanyl. Health officials reminded patients, caregivers, and health care professionals of the importance of appropriate storage, use, application, and disposal of fentanyl patches.

Fentanyl is an opioid analgesic used for the treatment of breakthrough pain. Fentanyl patches are applied to the skin and treat patients in constant pain by releasing the medicine over the course of three days.

The FDA evaluated a series of 26 cases of pediatric accidental exposures to fentanyl patches reported since 1997. Sixteen of these cases involved children two years old or younger. Of these 26 cases, 10 resulted in death and 12 in hospitalization.

The FDA safety alert states:

Young children are at particular risk of accidental exposure to fentanyl patches.  Their  mobility and curiosity provide opportunities for them to find lost patches, take improperly discarded patches from the trash, or find improperly stored patches, all of which may result in patches being placed in their mouths or sticking to their skin.

Physician-Patient Alliance for Health & Safety

In alarm fatigue, Force function, High Reliability Orgs, hospital, Patient Safety on April 15, 2012 at 6:56 am

What can be better than a caregiver-patient alliance for safety?

Check out this website from PPAHS

Improving health and safety involves many facets:

  • Innovative technology to provide for necessary monitoring of patient vital signs. For example, as the Wall Street Journal proclaimed in its story about Howard Snitzer “A little known device is shaking conventional wisdom for reviving people who suffer sudden cardiac arrest: People may be able to go much longer without a pulse than the 20 minutes previously believed.”
  • Health Care Providers who must make critical live-saving decisions, such as anesthesiologists who, as the American Society of Anesthesiologists says, “are responsible for administering anesthesia to relieve pain and for managing vital life functions, including breathing, heart rhythm and blood pressure, during surgery. After surgery, they maintain the patient in a comfortable state during the recovery and are involved in the provision of critical care medicine in the intensive care unit.”
  • Information on what works and how it enhances patient health and safety.”

Much of their site is dedicated to respiratory events and technology.

Here is an interesting post about children and sedation.  Is monitoring RR and o2 via pulse oximeter giving us a false sense of security?


Almost like being there…

In Force function, Patient empowerment, Resiliency on April 14, 2012 at 12:16 pm

Videos from the 2012 Heathcare design conference

Summary of Healthcare Design Conference

In culture, Patient empowerment, Patient Safety on April 11, 2012 at 11:13 am

Technology is so important for safety. More clinicians need to be at these conferences as the disruption of healthcare is evident in these presentations.  We need to move forward.

Patient empowerment is another theme at this yearly conference.  Patient empowerment is key to safety.


%d bloggers like this: