Statement on Preventing Harm from Oversedation
Oversedation results when the level of the patient’s sedation is greater than the desired therapeutic level of sedation. It can be associated with significant actual or potential patient harm such as respiratory depression, falls, and aspiration. The risk of oversedation is present in all patients receiving opioids, other respiratory depressants, or sedating agents. In particular, four medications (morphine, fentanyl, hydromorphone, and meperidine) are disproportionately involved in harmful medical errors. In addition, a number of agencies have issued alerts and advisories regarding the risks associated with dose confusion between hydromorphone (Dilaudid) and morphine.
The Commission has published the Statement on Preventing Harm from Oversedation as a starting point for hospitals to use in efforts to decrease patient harm associated with sedation. The statement is consistent with The Joint Commission’s recent Sentinel Event Alert, Safe Use of Opioids in Hospitals (2010).
Oregon Adverse Event Disclosure Guide
A RESOURCE FOR PHYSICIANS AND HEALTHCARE ORGANIZATIONS
The Oregon Adverse Event Disclosure Guide is intended to help Oregon’s physicians and healthcare organizations better understand the purpose of disclosure and provide resources to help develop and improve disclosure programs in Oregon healthcare organizations. The guide is organized in a question-and-answer format to help readers navigate to useful information.
Project JOINTS (Joining Organizations IN Tackling SSIs) is an initiative funded by the federal government aimed at helping hospitals implement the latest Institute for Healthcare Improvement (IHI) surgical site infection (SSI) prevention techniques for hip and knee arthroplasty surgeries. Oregon is one of only ten states selected to participate in the project – five states began in May 2011 and Oregon, along with four other states, began in April 2012. Oregon’s participation in Project JOINTS is scheduled to last through September 2012.
Putting Safe Surgery Checklists to Use
Some time ago, The New England Journal of Medicine reported that use of a simple checklist significantly reduces surgical complications and death. As of November 2010, all of Oregon’s 56 acute-care hospitals that perform surgery were using the checklist or pursing checklist implementation.
Press Release: Oregon Hospitals Make Surgery Safer
Safer Surgeries: Implementation of the WHO Surgical Safety Checklist in Oregon, Oregon IHI Network, 2010
Oregon Map of Checklist Adoption
Oregon IHI Network Safe Surgical Checklist (adapted from the WHO Surgical Safety Checklist)
Ambulatory Surgery Centers
The Centers for Medicare and Medicaid Services (CMS) is calling on all ambulatory surgery centers (ASC) to use a safe surgical checklist starting in 2012.
Preventing Unintentionally Retained Objects
In 2007, the Commission convened a workgroup to examine what was known regarding prevention of retained objects and to make recommendations that would decrease the possibility of a retained object after surgery for Oregon patients. The workgroup published a report, Preventing Unintentionally Retained Objects, which provides recommendations organized into practices essential to the prevention of retained objects, preferred practices, and practices that deserve further discussion and consideration.