patient safety concerns

ECRI: Top 10 Patient Safety Concerns for Healthcare Organizations

The ECRI Institute released its latest report, 2017 Top 10 Patient Safety Concerns for Healthcare Organizations. The report’s goal is to help hospitals and health systems decide where to focus patient safety initiatives.

We encourage you to read the the entire ECRI on the Top 10 Patient Safety Concerns, but wanted to highlight a few key areas.

Information Management in EHRs (#1)

“Healthcare organizations must approach health IT safety holistically. …Strategies include ensuring that users understand the system’s capabilities and potential problems [and] encouraging users to report concerns and investigating those concerns.”

Quality and reporting in many hospitals and health systems rely on individual recollections after an incident, which can be inaccurate or incomplete. The appropriate technology can provide healthcare organization with objective data to assess any incident and make measurable, team-focused improvements to the reporting and resolution process.

Patient Safety Resource: Case study—Achieving Clinical Clarity from Ventilator Overload. The Hospital for Special Care was able to achieve real-time surveillance of more than 100 patients on ventilation support. In addition, the hospital was able to use collected data for reporting to its audit committee, which monitors ventilator management performance and identifies potential areas of need.

Unrecognized Patient Deterioration (#2)

“Organizations can develop condition-specific protocols for an organized and speedy response and analyze work systems and processes to identify and address barriers.”

Several alarm techniques and strategies exist for identifying at-risk patients, including smart alarms. These allow for the analysis of the alarm signals themselves, but also the high-fidelity physiological data associated with them, including time trends, in-depth alarm sensitivity and statistical and predictive analysis.

Patient Safety Resource: White paper—Clinical Alarm Management & Reduction: Eliminating alarm proliferation in hospitals and health systems. This white paper outlines the current state of clinical alarm management, demonstrate how to establish a baseline of a hospital’s alarms, and explores innovative alarm reduction strategies to promote more efficient workflow, increase patient safety, and put hospitals on the path toward real-time patient monitoring and intervention.

Implementation and Use of Clinical Decision Support (#3)

“On an ongoing basis, organizations should monitor the effectiveness and appropriateness of CDS alerts, evaluate the impact on workflow, and review staff response to alerts. The tool should be redesigned as necessary.”

The truth is that the overwhelming majority of alarms endured by nurses, respiratory therapists and other caregivers have nothing to do with a patient’s medical condition. However, the fatigue and desensitization that results from caregivers responding to hundreds—or even thousands—of alarms every day is a clear and documented threat to patient safety. Technology can help get alarms under control—but it is not enough. Clinical and IT leadership, including nurses, respiratory therapists, biomedical engineers and information technology staff, must come together to develop the policies and standards necessary to bring meaning and action back to clinical alarms.

Patient Safety Resource: Article—“Why it’s time for an immediate hospital alarm intervention” by Jeanne Venella, DNP, MS, RN, CEN, CPEN, Chief Nursing Officer, Bernoulli. Published May 2016 in DOTMed.

Opioid Administration and Monitoring in Acute Care (#7)

“Organizations may wish to evaluate and address work system and process factors that may contribute to opioid administration errors. For certain patients, capnography or minute ventilation monitoring can supplement nurse monitoring.”

Both patient-managed and staff-administered pain medication are necessary for the patient’s well-being in the hospital. However, their use presents real risk of overdosing and death, especially for patients with complex chronic conditions and co-morbidities. Continuous monitoring can help improve patient safety while keeping the patient comfortable, but careful implementation is necessary to avoid a negative impact on the staff and environment the patient depends on for care.

Patient Safety Resource: Article—“Achieving Real-Time Respiratory Depression Surveillance of Post-Surgical Patients” by Jeanne Venella, DNP, MS, RN, CEN, CPEN, Chief Nursing Officer, and John Zaleski, PhD, CAP, CPHIMS, Executive Vice President and Chief Informatics Officer, Bernoulli. Published Feb. 8, 2017 in PSQH.

Inadequate Organization Systems or Processes to Improve Safety and Quality (#10)

“Proactive strategies can be used to examine processes, identify what can go wrong, and make the process less vulnerable to error before mistakes can occur. Strong preventive strategies, such as standardization and automation, should be explored.”

Technology plays a critical role in patient safety, but it is one piece of a larger solution. Achieving measurable progress in patient safety requires that hospitals identify and support internal champions in all relevant departments including, nurses, respiratory therapists, biomedical engineers, and information technology staff. These interdisciplinary experts must come together to assess the current state of patient safety environment—by unit and facility—including reviewing current protocols; identifying and developing targets for improvement; and evaluating appropriate interventions, policies, and standards. Without the input and expertise from hospital leadership, any patient safety solution will fall short of institutional goals and may put full adoption at risk.

Patient Safety Resource: Webinar—“The Threat of Alarm Fatigue on Patient Safety.”

Final Thoughts

Bernoulli is dedicated to providing clinicians with the technology-enabled capabilities necessary for improving patient safety in real-time. Our commitment to interoperability and vendor-neutral, open architecture both with regards to device connectivity and delivery of data and analytics to other systems of record enables hospitals and health systems to benchmark measureable, sustained improvements to patient safety.

As always, be sure to review our Resource Center to access real-world case studies, white papers, thought leadership and published papers and articles that will help your team make informed decisions about investing in enterprise-wide medical device connectivity, alarm reduction, patient safety analytics—all based on continuous, real-time data.

Follow us on LinkedIn and Twitter for additional news, tools and resources.

Cleveland’s News 5 – Dead in Bed – report on opioids

On November 18th Cleveland’s News 5 aired Dead in Bed: A deadly hospital secret. Dead in Bed is the result of a 5 month investigation that interviewed some of the nation’s most respected medical experts on why healthy patients are dying within hours of surgery.

Although the investigative report, stated it believed that new pain management standards implemented 15 years ago may be contributing to risk factors, seems like new news, the AAMI Foundation has been advancing safety in healthcare technology with initiatives on National Coalition to Promote Continuous Monitoring of Patients on Opioids and the Nation coalition for Alarms. Their kick off meeting National Coalition to Promote Continuous Monitoring of Patients on Opioids – in November of 2014 covered the Opioid and Sedative Use Increases the Risk of In-Hospital Cardiopulmonary Arrest and more.

This is an on-going issue that concerns the use and monitoring of patients being given opioids, Opioid deaths effects nearly everyone, regardless of race and has tripled over the last 20 years. This is a real issue that needs the healthcare industry’s attention.

To listen to the the full investigative here report from News 5 click here

To connect with the AAMI click here.

If you haven’t signed up for it there is still time to register for the Bernoulli sponsored webinar  “We See You When You’re Sleeping: Addressing Patient Safety Risks Surrounding Opioid-Induced Sedation” with presenter Jeanne J. Venella DNP, MS, CEN, CPEN on November 30th

Bernoulli CIO to Speak at BIOMEDevice Summit

John Zaleski, Bernoulli CIO, to Speak on Device Integration and Interoperability at BIOMEDevice Summit

MILFORD, CT—  December 7, 2016 – John Zaleski, PhD, CAP, CPHIMS, Bernoulli Executive Vice President and Chief Informatics Officer, will be a features panelist at the 2016 San Jose Connected Health Device Development Summit, Dec. 7-8, at the San Jose Convention Center in California.

Dr. Zaleski will appear on a panel discussion called Interoperability: Integrating Your Connected Device with the Hospital, Clinic and Home Ecosystems on Thursday, December 8, from 8:30am to 9:15am.

The panel will discuss:

  • The common interfaces used in the marketplace like Wi-Fi and space on the spectrum.
  • Provide updates on HL7 and IHE standards.
  • Explore better practices being used to address HIPAA privacy and security concerns during the onboarding process.

Dr. Zaleski will be joined by Steve Abrahamson, Director, Product Security Engineering, GE Healthcare; Steve Hegenderfer, Director, Developer Programs, Bluetooth; and Bill Saltzstein, President, Code Blue Consulting.

“Hospitals and health systems are constantly seeking ways to leverage data that flows from a device into a system of record. The use of the data to improve patient care management and clinical decision making comes immediately to mind—but that only scratches the surface of what is possible,” said Dr. Zaleski. “I’m looking forward to a lively and informative discussion.”

BIOMEDevice San Jose showcases emerging trends and innovations that will set the tone for the biomed industry in 2017 and beyond. The conference offers training on digital device trends and exploring effective ways to overcome barriers to market entry, all in a two-day Connected Health Device Development Summit. Register to attend.

Follow Bernoulli on LinkedIn and Twitter for additional updates, as well as access to case studies, thought leadership and other information.


ECRI Institute Evaluation of Ancillary Alarm Notification Systems Report

“Is your hospital or health system considering technology to help address The Joint Commission’s National Patient Safety Goal to reduce the risk of harm associated with clinical alarm systems?  The independent, well-respected ECRI Institute recently published an evaluation of Ancillary Alarm Notification Systems, including Bernoulli One™.  ECRI subscribers can access the report on the Health Devices website.”

Bernoulli Concludes Successful AAMI Foundation Patient Safety Event

Bernoulli client—the Hospital for Special Care—delivered presentation on ventilator alarm management

AAMI Foundation Patient Safety Event

AAMIRepresentatives from Bernoulli and its client, the Hospital for Special Care (HSC), joined 100+ attendees and 18 leading healthcare organizations at the AAMI Foundation’s regional meeting in Chicago. The two-day conference featured presentations on continuous monitoring of patients receiving opioids, alarm management and improvements to infusion therapy safety.

Connie Dills, MBA, RRT, RPFT, Respiratory Practice Manager at HSC, a Connecticut-based long-term acute-care (LTAC) hospital, delivered an insightful presentation detailing the success the hospital has had using the Bernoulli One™ platform to reduce and manage alarms on more than 100 ventilators in their facility. Results cited in Ms. Dills presentation included:

  • An 80% reduction in ventilator alarms that require clinical action
  • Enhanced ventilator alarm response time
  • No serious ventilator-related safety events in more than 13 years

A detailed case study of HSC’s successes with Bernoulli One™ can be found here.

“Alarm management and continuous monitoring for patients on opioids are two of the top patient safety priorities in healthcare today,” said Janet Dillione, CEO of Bernoulli. “Bernoulli OneTM supports hospitals and health systems in their efforts to achieve full compliance with the Joint Commission’s National Patient Safety Goal (NPSG) on clinical alarm safety and also enables continuous, real-time surveillance of patients connected to virtually any medical device. Our partnership with the AAMI Foundation allow us to engage with thought leaders on the frontlines as well as other industry partners to address these challenges.”

Other healthcare organizations that presented included Roper St. Francis Health System, St. Mary’s Health System, Newton-Wellesley Hospital, Evergreen Health, Johns Hopkins Hospital, University of Maryland Medical Center, Jefferson University Hospitals, Winchester, NCH Healthcare System, Hallmark Health, Western Maryland Health System, Allina Health, and Lancaster General Health. Bernoulli is a sponsoring partner of the AAMI Foundation’s Coalition for Alarm Management Safety and Coalition to Promote Continuous Monitoring for Patients on Opioids.