Did You Know…
The Commission offers these additional resources to support providers’ patient safety efforts:
Commission Newsletter »
Monthly newsletter with articles highlighting key issues in patient safety and updated information about the Commission
Patient Safety Reporting Program »
A confidential and voluntary program for healthcare facilities to report adverse event investigation findings and action plans
Early Discussion and Resolution »
A process for patients (or their representatives) and their healthcare facilities and providers to have an open and caring conversation if serious physical injury or death occurs during healthcare
Provider Resources »
Tools, reading, and websites to help healthcare professionals improve the safety and quality of services to patients
Action Alerts »
Up-to-date information about specific adverse events with recommendations for how providers can take preventative action
Assessing VTE Risk in Ambulatory Surgery Centers
Findings and Recommendations from an Oregon Workgroup
In light of data reported to the Patient Safety Reporting Program and the need for resources to reduce the risk of venous thromboembolism (VTE) in ambulatory surgery centers (ASCs), the Commission convened a short-term workgroup. This workgroup determined that the most critical area in need of support is the risk assessment process. Assessing VTE Risk in Ambulatory Surgery Centers presents six key findings related to effective VTE risk assessment and four recommendations to help ASCs standardize and improve VTE risk assessment.
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.