CPS Safety Watch/Alert – Respiratory Compromise

March 15, 2018 | By:

BACKGROUND

Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

Respiratory Compromise creates problems that are often serious and potentially life-threatening, but they are almost always preventable with the proper tools and approach. Appropriate patient monitoring and therapeutic strategies are necessary for early recognition, intervention and treatment.

Common themes include:

Lack of appropriate monitoring and early identification of respiratory compromise
Distractions, complacency or failure to identify high risk patients at transitions of care
Not anticipating respiratory complications or lack of situation awareness
Complications and risks from procedural sedation

ACTIONS TO TAKE:

Understand the pathophysiology and clinical factors of respiratory compromise
Early identification of patients at risk
Appropriate and timely patient monitoring
Appropriate and prompt interventions and treatment

RESOURCES
*Respiratory Compromise Institute

Thanks to Dr. Brian Froelke, CPS

BLOG:

PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.