Awareness, Involvement and Action: How Patients and Their Loved Ones Can Fight the Opioid Epidemic

The opioid epidemic is a major public health concern in the U.S. According to the Center for Disease Control and Prevention (CDC), 70,630 people died from drug overdoses and 10.1 million people misused opioid prescriptions in 2019 alone. Even more alarming is the fact that there are an estimated 180,000 serious opioid-related adverse events in inpatient settings recorded annually. Opioids are potent pain relievers so it is critical that anyone that has a prescription be properly informed about the potential risks – both in and out of the hospital setting.

The fight against the opioid epidemic is a hard and tricky one but there are ways to get involved and play a fundamental part in solving the problem. Awareness, involvement and action are three critical components to fight the endemic, here are some examples of how you can play a role:

  • Awareness: Act responsibly and be aware of available resources.
    • Take prescription drugs exactly as directed by your physician and dispose of any remaining medication properly.
    • Never allow anyone else to take the pills prescribed to you, don’t take them for unrelated conditions and always ensure they are out of children’s reach.
    • If a loved one is taking opioids, be aware of how the person feels and the amount of medication he or she is taking. Download the PatientAider® app on your cell phone. This free tool provides additional information about what you should do when you or a relative of yours is taking prescribed opioids.
    • New technologies are also available to help with opioid addiction. A person who is addicted to narcotics will face a difficult journey in trying to stop consumption so tools like Bridge, a neurostimulation device that targets areas in the brain to reduce opioid withdrawal symptoms, can help them through the process. This small device is placed behind the ear and sends electrical signals to the amygdala, the part of the brain that controls fears, pain and the emotional response to pain, reducing the symptoms of opioid withdrawal like anxiety, nausea and abdominal pain, among others.
    • If you know someone who is abusing opioids or taking them illegally, help and encourage them to seek professional support.
  • Involvement: Be active in your care plan and ask for monitoring.
    • Always be aware and educated on the type of medication being prescribed. Look around to see if a hospital displays their commitment to preventing adverse opioid events, and if it is not clearly visible ask to learn about the plans in place.
    • If a person is under patient-controlled analgesia (PCA), meaning that he or she has a pump releasing opioids to push when they feel pain, it is important that they are monitored. The Joint Commission, the organization that accredits hospitals, recommends continuous monitoring of oxygenation and ventilation of patients after surgery. Therefore, don’t be afraid to ask the hospital staff what monitoring protocols are in place.
    • Be prepared when taking a patient home. Unfortunately, when signs of an overdose occur it is often too late. At home care must include respiratory monitoring to help family members ensure that the patient has good ventilation. Additionally, to prevent respiratory depression, another important parameter to track is oxygen saturation. To control it, the patient needs to have continuous pulse oximetry with centralized alarms. Before discharge, ask the hospital what devices are available to help you monitor at home.
  • Action: Reach out to your legislation to address concerns. Today, the way opioids are prescribed and monitored vary by hospital. But new legislation is aiming to improve patient safety and reduce preventable opioid-induced injuries and deaths in inpatient settings.
    • Reach out to show your support for the Inpatient Opioid Safety Act of 2021 to help ensure that this issue is addressed proactively.
    • Connect with your legislators to ensure the Patients Right to Know Act of 2021 is implemented in your state. This act awards grants to states in order to educate their healthcare providers about opioid prescribing practices. To earn this grant, states must also have a law or regulation in place that requires providers to inform patients about the risks involved before prescribing an opioid for acute pain and also share alternative options.

Patients and their loved ones are a valuable element of ending the opioid epidemic. Never hesitate to ask questions and get involved in your own or your loved one’s treatment.

About the Author: Diane Perez, MD, is a member of the advisory board of the Patient Safety Movement Foundation. She has received numerous awards for her work as an advocate of healthy living and is passionate about patient safety. Perez is a resident of San Diego, living in the Bay Ho neighborhood.

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PSMF CEO Michael Ramsay Weighs in on the OIG Report for Adverse Events in Hospitals

In the month of October 2018, 25% of Medicare patients experienced harm during their hospital stay – for 43% of these patients, the harm events were preventable. The common types of harm events were related to medications, pressure ulcers, and surgical complications such as hypotension and hospital-acquired infections.

The cost of the harmful events was calculated to be in the hundreds of millions of dollars for the month of October. 64% of adverse events that resulted in patient death were preventable. Preventable events were commonly linked to substandard or inadequate care. The previous report in 2010 reviewing the month of October 2008 shows very similar numbers of patient harm events as this report.

Recommendations:

  • Given the scale and persistence of patient harm in hospitals over the last decade, since the last report: HHS leadership and agencies must work with urgency to reduce patient harm in hospitals
  • CMS to update its list of Hospital Acquired Conditions HACs
  • CMS to expand the use of patient safety metrics for healthcare payment
  • CMS to enforce hospitals tracking and monitoring of patient harm
  • AHRQ to update Quality Strategic Plans
  • AHRQ to optimize the use of Quality and Safety Review System
  • AHRQ to develop national clinical best practices to improve patient safety
  • AHRQ to identify and develop new strategies to prevent patient harm events in hospitals

To read the full Adverse Events in Hospitals OIG report from the U.S. Department of Health and Human Services, click here.

Healthcare Weekly

The Summit Session One Experience

Annually, the first quarter of the year marks the Patient Safety Movement Foundation’s highly anticipated World Patient Safety, Science & Technology Summit. Per usual, this year’s sessions were filled with empowering, crucial conversations with healthcare professionals and patient safety advocates committed to making a positive change in the medical field.  

This year’s summit united world leaders and experts in bringing together result-driven ideas and solutions to achieve the audacious goal of eliminating preventable patient harm. In addition, the summit also marked the Patient Safety Movement Foundation’s first 10 years of achievements and success.

As a student intern of the Patient Safety Movement Foundation, I had the honor of attending Session 1, a talk centered on “Overcoming Obstacles for Applying High Reliability Principles in Healthcare.” Moderated by Dr. Dave Mayer and led by Dr. Abdulelah Alhawsawi, Dr. Michael Privitera, and Mr. Keith Conradi, Session 1 explored various topics, such as patient safety’s application to different industries and thoughts on public health systems.

The panel began with introductions, beginning with Dr. Mayer, the former Chief Executive Officer of PSMF and executive director of the MedStar Institute for Quality & Safety. Also introduced were: Dr. Abdulelah Alhawsawi, a transplant and hepatobiliary surgeon and former Founding Director General of the Saudi Patient Safety Center; Dr. Michael Privitera, a consultation liaison psychiatrist; and Mr. Keith Conradi, the chief investigator of the English Healthcare Safety Investigation Branch. 

To kick start the session, Dr. Mayer shared a quote by Dr. James Reason: “to err is human”, also the title of the Institute of Medicine report. “James Reason says we can’t change the human condition, but we can change the condition under which humans work,” says Dr. Mayer, “HRO and resilient science has been studying this for over 30 years and have shown great success in other industries.” 

Branching out from the topic of other industries, a question was raised: over 30 years of research, what was it that could be learned from other industries that had successfully taken action and changed cultures to one dedicating safety as their top priority?

Mr. Keith Conradi, with his extensive aviation background, provided an interesting thought: “It’s not necessarily you, but it is the environment around you that actually contributes to where something may go wrong,” he said. 

Simply said, little errors aren’t a rarity; however, the system in place is what prevents them from becoming critical and causing harm. “Something that we often describe as a safety management system is pretty much mandatory in airlines across the world,” commented Mr. Conradi, “That means that it’s not only systematic, but it’s proactive.”

Mr. Conradi emphasized that healthcare would benefit from not simply reacting to circumstances, but rather taking a systematic approach. “One of the big things that we often are starting to recommend when we do investigations is that people implement a proper safety management system,” he said, in regards to his line of work. 

As a clinician, Dr. Michael Privitera found great interest in analyzing where most errors came from and discovered that “the most common causes of errors are system based, and that the most common reasons for clinician burnout are system based.” To Dr. Privitera, this posed the great question: what can we do about the system?

When it comes to medical error, unfortunately, some are human induced. Human casualties may happen because no person is completely perfect, but it is crucial that we take steps to prevent errors from happening at all. “How can we keep track of how long a person is working after the last patient is seen? So they’re better rested the next day?” questions Dr. Privitera. 

To Dr. Abdulelah Alhawsawi, focusing more on systems than individuals in the system may be a viable solution. In healthcare, there’s a larger focus on individuals in the system. “That’s another area that we could learn from [other] industries,” he says. 

Human errors could lead to “pointing fingers”- but in general, patient safety is not a simple black-and-white situation. On this topic, Dr. Privitera raised the point of “just the whole idea of not placing blame, but just to that effect, that it can happen.” 

Continuing on with the discussion of the individual, Dr. Privitera agreed on how there was much emphasis on the individual and the widely circulated idea that it’s simply on the individual’s error and ultimately their fault to bear. “But what about all the how upstream decisions may have affected resources?” asks Dr. Privitera, raising a thought-provoking question.

Ultimately, patient safety also comes in hand with “diffusing the issue of blame,” and as Dr. Privitera best put it, “realize this is human nature.” “We’re all in the human club. So this can happen,” he remarked. 

When it comes to the aviation industry, the system is better structured than healthcare; from training interviewers going to areas of mishap or danger immediately, whereas healthcare has a three to four week delay of schedule, the aviation industry has further acted upon their patient safety concerns. 

When asked about his experience in the aviation industry in regards to the system, Mr. Conradi shared that the aviation industry was able to harness much emphasis on simulation and simulated training. “We were able to embed that sort of culture every six months as pilots went through that particular emergency training and all the different scenarios,” he says. 

Another point noticed was the fact that in aviation, most states only have one regulator. Compared to the Federal Aviation Administration (FAA) of the United States, Britain has a Civil Aviation Authority. 

When coming into the field of healthcare, Mr. Conradi shared that he was surprised to see such a vast number of regulators. While the autonomy of various groups working as extended networks was an interesting concept, Mr. Conradi shared that it may potentially lay open space of mistakes to lead to harm.

Not only should systems be continually sought to be improved upon, accountability should be more seriously taken. “If we blame the system and process every time when there was preventable harm, that would almost be anarchy,” commented Dr. Mayer. With accountability, patient safety could be reduced in the future through actionable ideas. “We also as leaders have to be responsible and accountable to act on that and to ensure the safety of our patient population,” said Dr. Mayer.

Throughout this session, I was able to listen to different perspectives all over the world on their specific line of work and culture’s effect when it came to the healthcare system. It was truly enlightening to hear genuine questions raised in regards to the issue of patient safety and to hear potential ideas for the future as well. 

With our continued advocacy and passion for patient safety, we have the power to influence the healthcare system for the better. As affirmed by this session, to move forward, we must take responsibility to support positive outcomes for patients and individuals.

A huge thank you to the panelists, Dr. Dave Mayer, Dr. Abdulelah Alhawsawi, Dr. Michael Privitera, and Mr. Keith Conradi! On behalf of the Patient Safety Movement Foundation, I sincerely appreciate your words and support.

Patient Safety Movement Foundation Announces Winners of 2021 Humanitarian and Lewis Blackman Awards

IRVINE, Calif. – The Patient Safety Movement Foundation (PSMF), a global non-profit committed to achieving zero preventable patient deaths by 2030, announced the winners of its 2021 Humanitarian and Lewis Blackman awards at its 8th annual World Patient Safety, Science & Technology Summit (WPSSTS). President Bill Clinton, the 42nd President of the United States, was recognized with the Joe Kiani Humanitarian award, Javier Davila received the Beau Biden Humanitarian award and Jannicke Mellin-Olsen was honored with the Steven Moreau Humanitarian award. The 2nd annual Lewis Blackman award was presented to Ingrid Bonilla.

“Achieving our mission of zero preventable patient deaths by 2030 relies on individuals coming together to create change,” said Michael Ramsay, MD, CEO of Patient Safety Movement Foundation. “We are proud to recognize all four of this year’s winners for their individual efforts, leadership and commitment to improving patient safety globally.”

The Humanitarian Awards recognize leaders who have made significant progress in the last year eliminating or raising awareness of preventable patient deaths. This year, recipients were honored across three categories – the Joe Kiani award, Beau Biden award and Steven Moreau award. The Joe Kiani award was named after the founder of the Patient Safety Movement Foundation and recognizes individuals who are committed to the foundation’s mission. The Beau Biden award was created in 2018 to honor Beau Biden, former attorney general of Delaware, member of the Army National Guard and late son of President Joe Biden, for his devotion to public service and the safety of others, especially children. The Steven Moreau award is presented annually to a hospital administrator who possesses a zeal for improving patient safety at their hospital. This year’s recipients included:

  • President Bill Clinton, 42nd President of the United States, has been a long-standing supporter of patient safety. During his time in office, he was committed to expanding access to affordable, quality health care for all Americans. He received the first-ever Joe Kiani award for his continued support of the Patient Safety Movement Foundation and its goal to reach zero preventable medical deaths by 2030.
  • Javier Davila, PSMF ambassador in Mexico, former medical director at the Mexican Social Security Institute and head of medical education, research and health public policywas recognized with the Beau Biden award for his passion for public service and improving patient safety for others. Since joining PSMF, he has focused on promoting the culture of safety in Mexico and has helped build affiliations with many prestigious public and private hospitals, as well as establish relationships with numerous organizations to help further the mission.
  • Jannicke Mellin-Olsen, MD, DPH, has been a longtime patient safety advocate. Her passion for patient safety started during her residency at Trondheim University Hospital in Norway, where she worked on a number of patient safety initiatives. She received the Steven Moreau award for her continued efforts to spread the mission to stakeholders across Europe, as well as in her current clinical post at Baerum Hospital in Oslo, Norway.

The Lewis Blackman Leadership Award was established in 2020 to recognize active students or residents pursuing a career in healthcare who demonstrate exemplary leadership skills in patient safety that contribute to PSMF’s vision of eliminating preventable medical harm. It was designed in honor of Lewis Blackman, who died on November 6, 2000 at the age of 15, as a result of preventable medical harm in a healthcare setting with a poor culture of safety and inadequate training. Before his death, he was an outstanding student and his mother, Helen Haskell, has become an advocate for improving patient safety, especially through education.

  • Ingrid Bonilla, fourth year medical student at Medical University of South Carolina, has demonstrated an early commitment and passion for improving patient safety. During her time in medical school, she has worked with noted patient safety champions in South Carolina on new criteria to prevent central line infections, collected data on COVID-19 to determine how it presents itself in children and how they should be treated and has also focused on improving communication between patients, families and providers.

The Patient Safety Movement Foundation launched the Humanitarian Awards in 2013 to recognize individuals whose work helps advance patient safety and the Lewis Blackman Award was created in 2019. To learn more about the awards and past winners, visit: https://patient.sm/LewisBlackman.

The full WPSSTS event is available to watch on demand for $20 through May 9, 2022 at: http://patient.sm/summit2022 or free after May 9 at: http://patient.sm/summitYT.

The Patient Safety Movement Foundation Admonishes the Criminalization of Medical Errors

First and foremost, the Patient Safety Movement Foundation would like to express its deepest condolences to the family and friends of Charlene Murphey, a patient at Vanderbilt University Medical Center who died after a medication error in December 2017. As a global non-profit committed to eliminating preventable patient harm and death across the globe by 2030, we believe even one loss is one too many. 

Reaching zero harm will require healthcare systems and their staff to acknowledge faulty processes and embrace the reporting of near misses in order to create long-lasting change. However, on Friday, March 25, 2022, RaDonda Vaught, the nurse at Vanderbilt University Medical Center in Nashville, Tenn., was convicted of criminally negligent homicide and abuse of an impaired adult for the fatal medication error she made. From the outset of the incident, Vaught had told the truth and admitted the mistake. As an organization, we are saddened to see this case move to the criminal court system and believe criminalization of medical errors will rewind major gains the healthcare industry has made over the years in patient safety improvement. 

Many medical errors are preventable, and this incident underscores a systemic problem rather than an employee issue. The underlying question should be how do we prevent this from happening again?

Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur. 

The Department of Health and Human Services and Centers for Medicare and Medicaid Services has released their summary of the event. While the nurse has obligations to monitor a patient after administering a medication, it was clear in this instance that the root cause of this tragic incident was a “process error.” The medication dispensing machine should never have delivered medication for the patient that was not ordered by the clinician. 

To achieve our goal of zero patient harm and death from preventable medical errors, we need to foster a culture where leadership of hospitals and healthcare organizations support healthcare workers and encourage them to share near misses. Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care. Only by identifying potential problems and learning from them can change occur. Some healthcare systems have taken this one step further to celebrate near misses and to recognize the healthcare workers who have stepped forward to admit mistakes and be part of finding solutions to correct processes. 

The Patient Safety Movement Foundation is committed to helping healthcare organizations make the change needed to eliminate preventable medical errors, this includes: 

  • Creating high reliability organizations: To truly minimize preventable harm, the healthcare industry would benefit from becoming a highly reliable industry, such as aviation or nuclear power, which anticipates problems before they occur and are transparent about errors and root causes when they do happen. This requires a significant commitment by the executive team and governing body. A journey to high reliability will not succeed without their buy-in, continuous reinforcement and modeling of behavior. High reliability organizations need to create awareness about patient safety at every touch point across the organization, train leaders and staff in improvement processes, as well as commit to and model transparent, open and honest communication. 

 

  • Supporting the CANDOR method: The Communication and Optimal Resolution (CANDOR) toolkit is a well-studied Communication and Resolution Program (CRP) used by many healthcare organizations and practitioners to improve patient safety through an empathetic, fair and just approach to medical errors. This approach focuses on putting patients, families and caregivers first and providing timely, thorough and just resolutions after adverse events occur. Through this process, healthcare organizations and their patients can feel confident that processes will be examined in real-time and clear communication will occur throughout an unexpected event. Successful execution of the CANDOR process can lead to improved patient outcomes and satisfaction and the support of staff involved in the incident. 

The Patient Safety Movement Foundation stands with many other organizations condemning the approach of criminalizing medical error including, the Institute for Healthcare Improvement, American Nursing AssociationAcademy of Medical-Surgical Nurses, American Association for Respiratory Care and American Hospital Association.

Those interested in learning more about available resources can connect with the Patient Safety Movement Foundation, which exists to support healthcare organizations as they work towards zero preventable medical errors, as well as patients, families and caregivers impacted by medical error. Together, we can save lives.  

Respectfully, 

Michael Ramsay, MD, CEO of the Patient Safety Movement Foundation