Failure to Rescue - The Patient Safety Movement

Report
Patient Safety
Science & Technology Summit
2014
Founder:
2014 Summit Co-Convener:
Michael Ramsay, MD, FRCA
Chairman, Department of Anesthesiology,
Baylor University Medical Center,
President Baylor Research Institute
Founder:
2014 Summit Co-Convener:
Failure to Rescue
Founder:
2014 Summit Co-Convener:
Failure To Rescue
• When a complication is not recognized in a timely manner or treated
appropriately
– Many deaths and permanent disabilities could be avoided if:
– Adopted safe practices
• Implemented systems that facilitate patient safety
• Failure to Rescue is a measure of hospital quality
• More dependent on the hospital characteristics than the acuity of the
patient
Founder:
2014 Summit Co-Convener:
Failure to Rescue Post-Operative Surgical Patients
• Opioid analgesics are associated with adverse effects and cause respiratory
depression
- 0.5% of post-surgical patients
• Opioid-related adverse drug events – including deaths –reported to
The Joint Commission’s Sentinel Event database (2004-2011)
- 47% wrong dosing medication errors
- 29% improper monitoring of the patient
- 11% other factors including dosing, med interactions, adverse drug reactions
Founder:
2014 Summit Co-Convener:
Founder:
2014 Summit Co-Convener:
Founder:
2014 Summit Co-Convener:
APSF Recommendations (2011)
• All patients should have oxygenation monitored by continuous pulse oximetry
(Patient Surveillance System)
• Measure adequacy of ventilation when supplemental oxygen is needed
• Intermittent checks of oxygenation (oximetry) and ventilation (nursing
assessment) are inadequate
• Assessment of consciousness/sedation is critical
• Alarm fatigue and inadequacy of threshold-based alarms
Founder:
2014 Summit Co-Convener:
Joint Commission Sentinel Event Alert
(August 8, 2012)
Causes of adverse events
Lack of knowledge about potency
Improper prescribing/multiple opioids
Inadequate monitoring
Founder:
2014 Summit Co-Convener:
CMS Proposed Quality Measure #3040
(2013)
• Calls for “appropriate monitoring of patients receiving PCA”
• Defined as maximum period between documented respiratory rate, sedation
score and pulse oximetry does not exceed 2.5 hours
• Intermittent monitoring would meet the minimum requirement
• CMS received significant feedback that monitoring should be continuous
• Final determination not announced yet by CMS
Founder:
2014 Summit Co-Convener:
The Baylor Breathe Team
Mission: To eliminate patient harm
from postoperative respiratory depression
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Physicians
Nurses
Pharmacists
Administrators
Safety officers
Respiratory Therapists
Founder:
2014 Summit Co-Convener:
Founder:
2014 Summit Co-Convener:
Actions
• Standardized post-operative opioid (PCA) order sets. Over 50
different sets existed.
• Stopped continuous PCA in opioid naïve patients
• Instituted the :Oxygen Withdrawal Trial” in PACU
• Screened pre-operatively for patients at increased risk for respiratory
depression and applied blueberry wrist band
Founder:
2014 Summit Co-Convener:
Considerations
• Sedation precedes respiratory pauses. (Rising PaCO2)
• Sedation drugs can potentiate respiratory depression. (esp. phenergan,
benadryl)
• Avoid rapid dose escalation in opioid tolerant patients
• Avoid using opioids to meet an arbitrary pain rating
• Dosing should be based on individual’s need and condition
• Take extra precautions when transferring between departments and facilities
• Deployment of continuous monitoring of respiration, oxygenation with a closed
loop notification
Founder:
2014 Summit Co-Convener:
OUTCOMES
Orthopedic Surgical Floor 0.83 Rapid Response Team (RRT) Calls per Month
All Hospital: 8 RRT Calls per month reduced to 3.58
No Postoperative Respiratory Depression deaths
Founder:
2014 Summit Co-Convener:
Failure to Rescue
Andreas H. Taenzer, MD, MS
Helen Haskell
Susan Lorenz, DrNP, RN, NEC-BC, EDAC
Associate Professor of Anesthesiology and Pediatrics,
Director, Pediatric Acute Pain Service, DartmouthHitchcock Medical Center, Director of the Dartmouth
Patient Deterioration Prediction Laboratory (DP2L)
Founder of Mothers Against
Medical Error
Vice President of Patient Care Services/Chief Nursing Officer,
Princeton HealthCare System
J.P. Abenstein, MD
Dean Chittock, MD
ASA President Elect, Division of
Associate Professor of Medicine at the
Cardiovascular and Thoracic
University of British Columbia
Anesthesiology, Associate Professor of
Anesthesiology, Mayo College of Medicine,
Rochester, MN
Steven C. Moreau
Julianne Morath, MS, RN
President & CEO,
St. Joseph Hospital
President & CEO, Hospital Quality Institute,
California
Founder:
2014 Summit Co-Convener:
Failure to Rescue
Founder:
2014 Summit Co-Convener:
Patient Safety
Science & Technology Summit
2014
Founder:
2014 Summit Co-Convener:

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