Healthcare Consulting Services
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
Our multiple previous columns on delirium (see list at the end of this column) have mentioned multiple risk factors for the development of delirium in hospitalized patients. But a new risk factor for postoperative delirium has just been uncovered: obstructive sleep apnea (Flink 2012). The authors prospectively evaluated 106 nondemented elderly patients undergoing elective knee arthroplasty for delirium and found delirium in 25% of cases. The incidence of delirium in the 15 patients who had known obstructive sleep apnea (OSA) was 53%, compared with 20% in those without known OSA. In fact, in multivariate analyses, the only independent risk factor that emerged for delirium in this population was OSA. Patients with OSA were more than 4 times more likely to develop delirium. It was a well-done study in which the CAM (Confusion Assessment Method) and the DRS-R-98 (Delirium Rating Scale-Revised-98) were utilized on post-op days #2 and #3 (most patients were discharged by day #3) to identify patients with delirium and measure its severity. The incidence was highest on post-op day #2 as has been seen in prior studies and two-thirds of the cases had improved by post-op day #3.
The authors readily state that this study should be hypothesis-generating rather than showing a definitive cause and effect relationship between OSA and delirium but the findings are nevertheless striking and thought provoking.
The authors speculate on the potential mechanisms linking OSA and delirium. Obviously hypoxemia is suspected as a major factor and they speculate it might reduce ATP and synthesis of cholinergic precursors (reduced cholinergic activity has been supported as a mechanism of delirium in research settings). The accompanying editorial (Bateman 2012) notes that patients with OSA are most vulnerable to hypoxia on postoperative nights 2 and 3. Flink and colleagues also raise the possibility that inflammatory factors might play a role. Given the slight delay in the appearance of postoperative delirium one might also wonder about the possible role that REM rebound might play and its relationship to both OSA and postoperative delirium.
Recently, a clinical research group in the Netherlands had developed and validated a risk model for predicting delirium in hip fracture patients (Moerman 2012). Items considered in that model included prior episodes of delirium, presence of dementia, age, clock drawing, hearing and vision impairments, problems with ADLs, and alcohol or substance abuse. The tool was pretty good at predicting delirium in this patient population. This population was clearly different from that in the Flink study but it would be interesting to go back and see whether OSA might have been identified in the Netherlands population.
In our August 17, 2010 Patient Safety Tip of the Week Preoperative Consultation Time to Change we noted the relative ineffectiveness of the typical preoperative assessments done today. Instead of the intense focus on potential cardiac complications, we instead advocated for more focus on identifying frailty and risk factors for things like postoperative delirium and obstructive sleep apnea. Little did we know that those two might be interrelated! Admittedly there are a whole host of risk factors for delirium that should be considered in many patient populations. But now it makes sense to also screen for OSA, particularly in nondemented patient cohorts about to undergo elective surgical procedures. Screening for OSA is doubly important, given all the attention weve given to managing opiate therapy in the postoperative period (see links below).
Given the simplicity of screening for OSA with tools like the STOP-Bang questionnaire, there is really no good reason that such screening should not be part of the preoperative assessment, whether being done by an anesthesiologist, internist, hospitalist, or surgeon. It is incredible how often we send patients for cardiac stress testing preoperatively despite lack of clearcut evidence for its utility and cost-effectiveness in this population. Yet simple tests that can be done in a few minutes in the office, like the STOP-Bang questionnaire or the Timed-Up-And-Go Test (see our November 2011 Whats New in the Patient Safety World column Timed Up-and-Go Test and Surgical Outcomes), that are highly predictive of postoperative complications are seldom part of the preoperative evaluation.
Some of our prior columns on delirium assessment and management:
See some of our prior columns on obstructive sleep apnea in the perioperative period:
Patient Safety Tips of the Week:
June 10, 2008 Monitoring the Postoperative COPD Patient
August 18, 2009 Obstructive Sleep Apnea in the Perioperative Period
August 17, 2010 Preoperative Consultation Time to Change
July 13, 2010 Postoperative Opioid-Induced Respiratory Depression
February 22, 2011 Rethinking Alarms
November 22, 2011 Perioperative Management of Sleep Apnea Disappointing
Whats New in the Patient Safety World columns:
Flink BJ, Rivelli SK, Cox EA, et al. Obstructive Sleep Apnea and Incidence of Postoperative Delirium after Elective Knee Replacement in the Nondemented Elderly. Anesthesiology 2012; 116(4): 788-796, April 2012.
Bateman BT, Eikermann M. Obstructive Sleep Apnea Predicts Adverse Perioperative Outcome: Evidence for an Association between Obstructive Sleep Apnea and Delirium. Anesthesiology 2012: 116(4): 753-755, April 2012.
Moerman S, Tuinebreijer WE, de Boo M, et al. Validation of the Risk Model for Delirium in hip fracture patients. Original Research Article. Gen Hosp Psychiatr 2012; 34(2): 153-159
April 10, 2012
Error Disclosure by Surgeons
Weve done several columns promoting disclosure and apology after medical errors as being the right thing to do. One of the gray zones has always been in deciding which errors to disclose and whether to disclose errors in which no harm came to patients. An excellent paper (Chamberlain 2012) appeared last month in the surgery literature about disclosure of nonharmful medical errors and other events. We all have a tendency not to disclose near-misses to patients. But the Chamberlain article rightly points out that determination of harm is not a straightforward issue. What may not seem to have caused harm currently may, in fact, lead to harm in the future. The article discusses the ethical issues involved and advocates for taking view from the patients perspective. Research shows that most patients want to be made aware of mistakes and potential mistakes and that such disclosure usually improves the patient/physician relationship. Moreover, physicians who disclose the error to the patient/family are also then likely to report the error to the organization, perhaps leading to lessons learned that can help prevent future occurrences that might cause harm.
The article then has several practical recommendations about how to disclose medical errors to patients:
We, of course, advocate that the apology should really be the initial part of the discussion. It sets the tone for the remainder of the discussion and is critical in maintaining trust in the physician/patient relationship.
The article also notes that informed consent done before surgery also sets the tone for any subsequent disclosure. Informed consent should provide the patient with both the potential benefits and risks of surgery and a discussion of what would ensure if any of the risks came to pass.
But in reality there is a gap between the intent a physician has regarding error disclosure and the actual act of disclosure. A new paper (Ghalandarpoorattar 2012) reported the results of a survey given to surgical attendings and residents. Two error scenarios were presented, one a relatively minor one and the other major, and respondents were asked a series of questions about their attitude toward disclosure and their actual practices. Though the study was done in Iran we suspect that the results would probably not differ a whole lot if the survey were given in multiple sites in the US. About half said they would disclose the error in the major scenario and about 40% in the minor scenario, though almost 2/3 would disclose if asked by the patient about the event. Over half admitted they had made mistakes in the past year but only 16.7% had disclosed that error to the patient. The four top barriers to disclosure were: (1) fear of malpractice lawsuit (2) fear of loss of the patients trust (3) fear of the patients family members emotional response and (4) fear of losing professional fame among colleagues. And despite the fact that the literature suggests that disclosure and apology mitigate at least the first three outcomes, very few of the respondents actually believed what the literature says. Interestingly, those that did do disclosure were very satisfied with doing so, even those that eventually were involved in litigation.
Interestingly, in a survey of clinical pathologists and laboratory directors in the US (Dintzis 2011) results were strikingly similar (See our March 6, 2012 Patient Safety Tip of the Week Lab Error). Despite widespread support for reporting errors via hospital error reporting mechanisms, only 16.2% ever disclosed a serious error to a patient. But rather than being deterred by fear of malpractice suits, their main barriers to disclosure were thoughts that the patient would not understand what he/she was being told or that the physician would not be able to explain clearly. Nevertheless, those that were involved in direct disclosure to patients were highly satisfied with the experience.
Obviously we need to do a better job making it easier for all physicians to do the right thing and do disclosure and apology in an honest and caring way.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 Serious Incident Response Checklist)
June 16, 2009 Disclosing Errors That Affect Multiple Patients
June 22, 2010 Disclosure and Apology: How to Do It
September 2010 Followup to Our Disclosure and Apology Tip of the Week
Other very valuable resources on disclosure and apology:
Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Disclosure of "Nonharmful" Medical Errors and Other Events. Duty to Disclose. Arch Surg. 2012; 147(3): 282-286
Ghalandarpoorattar SM, Kaviani A, Asghari F. Medical error disclosure: the gap between attitude and practice. Postgrad Med J 2012; 88: 130-133
Dintzis SM, Stetsenko GY, Sitlani CM, et al. Communicating Pathology and Laboratory Errors. AJCP 2011 135:760-765
Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. IHI Innovations Series 2010. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2010
Canadian Patient Safety Institute. Canadian Disclosure Guidelines. May 2008
Massachusetts Coalition for the Prevention of Medical Errors. When Things Go Wrong. Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. 2006
The American College of Physician Executives. Disclosure and Apology Toolkit.
April 17, 2012
10x Dose Errors in Pediatrics
A new study (Doherty 2012) has again raised awareness of the problem of 10-fold medication errors. Several of our previous columns (see our Patient Safety Tips of the Week for March 12, 2007 10x Overdoses, September 9, 2008 Less is More.and Do You Really Need that Decimal?, and January 18, 2011 More on Medication Errors in Long-Term Care) provided examples of how 10-fold overdoses occur in a variety of settings.
Everyone knows the classic scenario where the abbreviation U for units gets misinterpreted as a zero and leads to a 10-fold overdose. Another example is when a drug ending in the letter L appears without sufficient space between it and the subsequent dose numbers. For example propranolol10mg gets interpreted as propranolol 110 mg.
We pointed out potential problems with misprogramming PCA (or other infusion) pumps. The data entry person may double press a key (or the key may become stuck) resulting in, for example, 88 instead of 8. Also, during data entry it is possible to think one hit a decimal point but it fails to print out. Thats why having a policy requiring a second independent observer verify the dosage or rate on such pumps makes sense (however, keep in mind that error rates from other industries tell us that one who oversees someone elses work typically does so in error up to 10% of the time!).
Another problem that occurs is when you include any digits following a decimal point. You all know you should never use a trailing zero, i.e. a zero following a decimal point, because if the decimal point is not seen there is a risk of a 10-fold (or higher) overdose. But what about other numbers following a decimal point? They are important in certain circumstances (eg. a dose of 0.3 mg or 2.7 mg). However, at higher doses they become much less relevant. For example, lets say you performed a calculation and the result was a recommended dose of a drug is 72.2 mg. Is there really a difference if the patient gets 72 mg. or 72.2 mg of most drugs? Yet ordering the latter dosage increases the risk that the decimal point may not be seen or not input into a computer or missed in a faxed order and the patient gets a 10x overdose. So we strongly recommend that in writing medication orders one specifically decides whether such fractional doses are important or merely place the patient at increased risk of an error.
We also pointed out the ease with which decimal points can be missed on faxed or photocopied orders or on carbon-copy sheets from triplicate order forms. And verbal orders are also prone to error (see our January 10, 2012 Patient Safety Tip of the Week Verbal Orders). For example, while it is not technically a 10-fold error look at the following scenario: certain doses, particularly those including a -teen (such as 18) may be misunderstood as having a -ty (such as 80). So spelling out the dose during read back may be appropriate (for example, one-eight).
The new study (Doherty 2012) provides a look at 10-fold dosing errors in a pediatric hospital setting over a 5-year period. It raises an issue weve previously ignored: 10x dosing errors are not always overdoses! They note that almost 30% of the 10-fold dosing errors they found would have resulted in significant underdosing with resultant loss of efficacy.
Over the 5-year period they found 252 instances of 10-fold medication errors. Though the vast majority were intercepted before reaching the patient and did not result in patient harm, 22 did result in patient harm. The overall rate of 10-fold errors was 0.062 per 100 patient days. Since this was a retrospective review taken from voluntary incident reporting the authors acknowledge that the true incidence may be higher.
They note that the errors occurred in all phases of the medication process (prescribing, transcribing, dispensing, administering, and monitoring), though the prescribing and administration phases were overrepresented. The three classes of drugs most often involved were opioids, antimicrobials, and anticoagulants. The individual drugs most often involved were headed by morphine and heparin.
The authors do a very good job identifying both sources for the errors and contributing factors. Dosage calculation errors and incorrect programming of delivery devices were the top sources for the errors. But they note that paper-based ordering was frequently an enabling factor. On the other hand, CPOE failed to block almost as many 10-fold errors. In addition, overriding of alerts on delivery devices was also a frequent enabler. Simultaneous programming of multiple intravenous pumps was another mechanism. And, as could be anticipated, urgent clinical scenarios were more prone to errors.
Where we had previously talked about sticking keys or keys that dont work on infusion pumps, they noted that the keyboard layout on many pumps may lead to errors. They point out that the zero, decimal point, and confirm or enter keys are often in close proximity on many keyboards, making it too easy to hit more than one key at the same time.
The authors put together many excellent recommendations to minimize the risk of 10-fold errors. For one thing, remove the need to do a calculation whenever possible. For instance, create order sets for fixed-dose opioids that require only input of the patients weight. Having decision support systems (tied to CPOE, barcoding systems, and automated dispensing machines) that flag doses of medications falling outside conventional dose ranges is another good way of helping avoid 10-fold medication errors. But beware that computer systems in their study were often enablers since they allowed many 10-fold errors to pass through the system. They go on to provide multiple recommendations for each of 8 areas needing the most attention. This article is definitely worth your reading.
Doherty C, McDonnell C. Tenfold Medication Errors: 5 Years Experience at a University-Affiliated Pediatric Hospital. Pediatrics 2012; peds.2011-2526; Published online April 2, 2012
April 24, 2012
Fire Hazard of
Skin Preps, Oxygen
The UK National Patient Safety Agency (NPSA) has recently released a signal regarding the risk of alcohol-based skin preps in contributing to surgical fires (NPSA 2012). This Signal addresses the risk of a patient being burned when diathermy is used in the presence of alcohol-based skin preparation solutions.
They identified 23 incidents of fire in which the involvement of skin prep was clearly stated and another ten incidents where diathermy was used and the involvement of skin prep was likely but not stated. Four of these incidents were reported as resulting in death or severe harm to the patient.
Key contributing factors found include:
insufficient time for drying of the skin prep solutions before commencement of surgery
pooling of the skin preparations
They cite recommendations in the guidance in The Standards and Recommendation for Safe Perioperative Practice (2011) from The Association for Perioperative Practice (AfPP) which state: Alcoholic skin preparations and other alcohol-based or aerosol products may ignite if they come into contact with sparks from electrosurgery. This can be avoided by not allowing alcoholic prep solutions to pool around the site of surgery while prepping, and allowing them to dry or be dried with a surgical swab prior to the start of any surgical procedure (MDA 2000). The practitioner should also be aware of the risk that the prep solution will not be able to evaporate if covered with impervious single use drapes.
A similar surgical fire occurred during a C-section in New Zealand. A report of that fire (Waitemata District Health Board 2002) has a very good discussion on the skin preps and their risk for fire. They pose three key questions:
1) Is it necessary to use alcohol in the skin preps for the specific procedure being performed?
2) If so, what methods/practices could be used to make it safer?
3) What volume of solution is required to make an effective skin preparation and what is the best form of application?
Note also that in our January 2011 Whats New in the Patient Safety World column Surgical Fires Not Just in High-Risk Cases pooling of the alcohol-based skin prep under the buttocks of a patient having a C-section in Israel was a key element in producing a surgical fire.
In both the New Zealand case and the Israeli case, the volume of skin prep used was an issue. Common to several of the reports of fires (including an example given in the UK NPSA signal), additional skin prep was applied after the initial prep. The volume is important because the amount of run-off is important. It is the run-off that often saturates drapes, etc. and ultimately serves as the fuel for the fire.
The importance of the applicator becomes apparent when we discuss the volume issue. In New Zealand they had, over time, switched from using a forceps to the sponge applicator because the latter allowed for speedier application of the skin prep. But the amount of run-off is considerably higher with the sponge applicator. Weve seen a similar case occur shortly after a hospital changed from a 10.5 ml sponge applicator to the same prep with a 26 ml applicator.
Allowing sufficient time for the skin prep to dry and any alcohol vapors to disperse is critical. We know of some hospitals that use a timer to ensure that sufficient time is allowed for that drying to occur.
In New Zealand the hospital(s) abandoned the use of alcohol-based skin preps for ob/gyn procedures, moving instead to aqueous-based skin preps, especially in view of lack of a clearcut difference in surgical site infections by skin prep type for such ob/gyn procedures.
The New Zealand report also makes mention that the colorless nature of some of the alcohol-based skin preps may make it difficult to identify run-off. Apparently manufacturers had, over time, removed the coloring from these preps because of allergies. The investigators of the surgical fire noted that having some coloring would likely help staff identify any run-off. Tinted preparations are commonly used in the US.
The debate over which skin prep is the safest and most effective is not yet fully answered. While there is some data suggesting that alcohol-based chlorhexidine preparations may be superior to povidone-iodine in preventing SSIs (Keller 2011), the fire risk associated with the alcohol-based preps must be considered as well. Particularly if the surgery is one in which the risk of SSI is generally low, it may make more sense to use povidone-iodine. Remember, we are dealing with relatively low risks in either case (but you sure dont want either an SSI or a surgical fire).
Oxygen is the other key factor in many OR fires. In our December 13, 2011 Surgical Fires Again we noted two cases of surgical fires occurring in patients having minor surgical procedures on the head. Though the surgical prep does not appear to have been a contributing factor, the report of the investigation done on one of those surgical fires provides some other insights (Chasteen 2012). In this case, a young woman was having sebaceous cysts removed from the back of her head. The procedure was being done with her in a prone position. Moderate sedation was used with fentanyl, versed and ketamine intravenously. Oxygen was being delivered via a face mask at 10 L/min. The skin was prepped with betadine and apparently no alcohol-based skin prep was used. Upon the third activation of the Bovie a flash fire was noted from under the surgical drape covering the operative site on her head, followed by a swoosh and flames between the patients oxygen mask and her face. The patient suffered first and second degree burns of the face in the area under the mask and a single spot of a third degree burn on the exterior portion of a nostril. Photos of the charred mask appear in the report.
The investigation included interviews of all parties, collection of multiple items from the OR, review of the literature, and two experiments to try to recreate the circumstances (which did not result in fire). They discuss multiple theoretical scenarios that might have led to this surgical fire but dismiss most of them as improbable.
Probably most important is the discussion of the type of face mask used to administer oxygen. This was a rather loosely-fitting mask that allowed oxygen to escape through holes in the connector and sides and edges of the mask. It was apparently not the oxygen delivery method usually used in this OR and was apparently chosen because they were concerned that nasal prongs might become dislodged with her in the prone position.
Though in their recommendations they suggest against use of such a face mask and recommend use of room air unless necessary to use a higher concentration of oxygen, they dont go into much detail. But those are the key points in this case. In our November 2009 Whats New in the Patient Safety World column ECRI: Update to Surgical Fire Prevention we discussed the 2009 ECRI update of its New Clinical Guide to Surgical Fire Prevention. The 2009 key change in clinical practice is discontinuing the open delivery of 100% oxygen during procedures done during sedation and where high concentrations of oxygen are needed the airway should be secured. They discuss ways to minimize the concentration of oxygen being used in a variety of scenarios. The APSF recently highlighted the importance of this in their Winter 2012 newsletter (APSF 2012) and provide an algorithm regarding use of oxygen. Perhaps the most important question to ask is: does the patient need supplemental oxygen? Most probably do not, in which case room air should be used. But if greater than 30% oxygen concentration is needed to maintain oxygenation, the airway should be secured with an endotracheal tube or supraglottic device. In cases where supplemental oxygen at less than 30% is medically necessary they recommend use of a delivery device such as a blender or common gas outlet to maintain concentration below 30%.
However, just as important is timely communication between the surgeon and the anesthesiologist. As the surgeon plans to use the Bovie (or other potential heat source) he/she needs to let the anesthesiologist know and then the oxygen flow may be reduced or stopped temporarily. A period of time for allowing dispersal of oxygen should then pass before the surgeon uses the Bovie.
Please also see our prior columns on surgical fires:
Patient Safety Tips of the Week:
Whats New in the Patient Safety World columns:
NPSA (UK). Risk of skin-prep related fire in operating theatres | Signal. 28 February 2012
Nishihara Y, Kajiura T, Yokota K, Kobayashi H, Okubo T. A comparative clinical study focusing on the antimicrobial efficacies of chlorhexidine gluconate alcohol for patient skin preparations. J Infus Nurs 2012; 35: 44-50
Keller DM. Preoperative Chlorhexidine Wash Superior to Povidone-Iodine.
Medscape News. September 30, 2011
51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC): Abstract K-480. Presented September 18, 2011
Waitemata District Health Board. Report into the Operating Theatre Fire Accident 17 August 2002. Final Report. 29 September 2002
Chasteen CE, Traylor J, Fiedor K, et al. A Report On Potential Causes Of A Fire In An Operating Room At North Okaloosa Medical Center. November 29, 2011
ECRI Institute. New clinical guide to surgical fire prevention. Health Devices.
ECRI Institute. October 2009: 314-332 (www.ecri.org).
Stoelting RK, Feldman JM, Cowles CE, Bruley ME. Surgical Fire Injuries Continue to Occur. Prevention May Require More Cautious Use of Oxygen. Anesthesia Patient Safety Foundation (APSF). APSF Newsletter 2012; 26(3): 41,43 Winter 2012
May 1, 2012
More LEAN Successes
LEAN, borrowed largely from Taiichi Ohno and Kiichiro Toyoda and the Toyota Production System, is both a performance improvement tool and a unique culture. Our October 11, 2011 Patient Safety Tip of the Week LEAN in the Lab described how one organization used LEAN principles to improve lab safety and efficiency. That article nicely described most of the principles used in LEAN.
A new study (Hydes 2012) shows how LEAN principles helped improve efficiency in a GI endoscopy unit. The organization had been managing upper GI endoscopy patients who did not require sedation in the same manner they handled all their colonoscopy patients who did require sedation. They employed some key concepts from LEAN thinking to redesign their processes and workflows. Those principles included viewing the process from the patients value perspective, removing steps that did not add value from the patient perspective, value stream mapping, removal of bottlenecks or other rate-limited steps, and improved handoffs.
They began with a value stream map of the current state. In the article they actually show a picture of the handwritten flow diagram. That is an early step not only in LEAN projects but also in FMEAs (failure mode and effects analyses) or many other performance improvement projects. Only by doing that do you get a good feel for where your opportunities to remove unnecessary or wasteful steps (muda) are. Part of that process includes determining movement of the patient and staff as they are going through the process. And dont forget to begin your map well before arrival of the patient at the GI unit, since many of the wasteful parts of your process may involve pre-procedure paperwork or other things that take place in preparation for the visit. They identified 22 steps in their current state process, 19 after arrival of the patient. And they found that the total patient journey ranged from 52 to 375 minutes. They identified 5 bottlenecks in their process and 3 handoffs. Of those steps they identified only 9 that added value from the patient perspective. Cuttting out those steps that did not add value reduced the total time necessary considerably. Ultimately they were able to reduce the total number of steps from time of arrival to discharge from 19 to 11 steps. Importantly, they reduced the number of bottlenecks from 5 to 3 and eliminated all 3 handoffs. This resulted in considerable reduction of wasted time from the patient perspective and an increase in the amount of valued time (eg. time spent with the endoscopist).
Two of the bottlenecks they eliminated were pre-procedure checks in the recovery unit and findings discussed with the nurse. Both of those steps would have been necessary in cases with sedation but were no longer necessary in this patient population. Because the patients were not sedated, the need for a post-procedure recovery unit and its staffing were no longer needed. So the project resulted not only in an improved process from a patient satisfaction perspective but also resulted in economic savings from improved efficiency. Patient satisfaction with the new redesigned process was good and they piloted the redesigned process at another site with similar good results.
Emergency Departments have also had considerable experience with LEAN. One study (Dickson 2009) analyzed LEAN implementations in EDs at 4 different hospitals. They found that the closer hospitals followed the original Toyota production system principles, the more successful they were in achieving improvements. Keys to success were active participation and ownership by frontline staff combined with continuous support and commitment to LEAN by leadership. They also noted that improvements in patient satisfaction typically lagged behind LEAN implementation by a year. That paper stresses that LEAN is a tool and that the culture of the organization and individual area are critical to the success or failure of any performance improvement project regardless of the tools used.
Another LEAN project improved turnaround times (TAT) for CT scans in the ED (Humphries 2011). That project reduced such TAT by 20 minutes. It involved allowing the CT technologists to actively pull patient through the ED, reduced use of oral contrast for abdominal CT scans, matched technologist working hours to ED volume surge, use of wireless devices to improve communication between the ED and the radiology department, and provided active feedback to technologists.
A critical review of ED LEAN projects (Holden 2011) identified 18 published articles from 15 ED LEAN implementations. It is an excellent review of the principles of LEAN and reiterates some of the success factors and barriers noted above. Though it concludes that all studies basically showed some improvement after implementation of LEAN projects, it points out that many of the outcome measures were more anecdotal rather than hard patient quality outcome measures or patient safety measures and that some degree of publication bias likely exists. It points out the real need to also have more formal measures of effects of LEAN on staff.
The accompanying editorial (Dart 2011) highlights the success of LEAN thinking at Denver Health. It stresses the disparity between the way the customer (patient) perceives the system and the way the healthcare system sees itself. Muda, the waste or non-value-adding steps in processes, both infuriates patients and frustrates healthcare workers. He stresses that the keys to success are the insights of frontline staff combined with the executive power to authorize change. Though LEAN is a bottom-up revolution it unites frontline staff, middle management, and executive leadership.
LEAN has also been used to improve efficiency and efficacy in systems for cataract surgery (van Vliet 2010) and Mark Graban in his book Lean Hospitals (Graban 2011) gives numerous examples of success stories of LEAN in healthcare.
We, of course, always caution you with any redesign project to anticipate possible unintended consequences and make sure your outcome measures include hard patient outcomes. Improved patient satisfaction could be easily offset by just a few significant avoidable complications. So make sure that you look at multiple quality measures as outcome variables, not just your satisfaction and financial variables. Our biggest criticism of studies on LEAN in healthcare has been the tendency to focus metrics on soft outcomes such as process measures and measures of satisfaction rather than on hard patient outcomes.
LEAN implementation is not always easy. William Millard, in a perspective on LEAN from an emergency department view (Millard 2011), notes the many barriers and facilitators important at some of the healthcare pioneers in LEAN such as Virginia Mason, University of Colorado, and Parkland/University of Texas Southwest. He ends with a description of how LEAN principles in CVS Pharmacys MinuteClinic chain have resulted in concepts that now represent challenges to traditional hospital EDs.
For those of you new to the LEAN world, the Serrano article (Serrano 2010) highlighted in our October 11, 2011 Patient Safety Tip of the Week LEAN in the Lab and the Holden paper (Holden 2011) noted today provide a great introduction to basic concepts and principles of LEAN. For those of you who are looking for more detail on LEAN in healthcare the second edition of Mark Grabans book Lean Hospitals is now available.
Hydes T, Hansi N, Trebble TM. Lean thinking transformation of the unsedated upper gastrointestinal endoscopy pathway improves efficiency and is associated with high levels of patient satisfaction. BMJ Qual Saf 2012; 21: 63-69 Published Online First: 13 September 2011 doi:10.1136/bmjqs-2011-000173
Dickson EW, Anguelov Z, Vetterick D, et al. Use of Lean in the Emergency Department: A Case Series of 4 Hospitals. Annals of Emergency Medicine 2009; 54(4): 504-510
Humphries R, Russell PM, Pennington RJ, Colwell KD. Utilizing Lean Management Techniques to Improve Emergency Department Radiology CT Turnaround Times (Abstract). Annals of Emergency Medicine 2011; 58(4): S248
Holden RJ. Lean Thinking in Emergency Departments: A Critical Review. Annals of Emergency Medicine 2011; 57(3): 265-278
Dart RC. Can Lean Thinking Transform American Health Care? Annals of Emergency Medicine 2011; 57(3): 279-281
van Vliet EJ, Sermeus W, van Gaalen CM, et al. Efficacy and efficiency of a lean cataract pathway: a comparative study. Qual Saf Health Care 2010; 19: 1-6 Published Online First: 22 April 2010 doi:10.1136/qshc.2008.02873
Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. Second Edition. Productivity Press 2011
Millard WB. If Toyota Ran the ED: What Lean Management Can and Can't Do. Annals of Emergency Medicine 2011; 57(6): A13-A17
Serrano L, Hegge P, Sato B, et al. Using LEAN Principles to Improve Quality, Patient Safety, and Workflow in Histology and Anatomic Pathology. Advances in Anatomic Pathology 2010; 17(3): 215-221
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May 8, 2012
Importance of Non-Technical Skills in Healthcare
Non-technical skills are as important or even more important than technical skills in a variety of fields of healthcare, just as they are in aviation, the military, or a variety of high-risk industries. Especially in areas where events are rapidly evolving, skills such as situational awareness and ability to communicate and work in teams are critically important. So it should be no surprise that these non-technical skills have been studied most often in the OR and ER.
In our March 2012 Whats New in the Patient Safety World column Human Factors and Operating Room Safety we noted an article on surgeons non-technical skills (Yule 2012) which provides excellent insight into key skills such as situational awareness, decision-making, leadership, communication and teamwork.
So what do we mean by non-technical skills? These are the more cognitive and social skills that are key elements in fostering good teamwork and collaboration and include some of the following:
Non-technical skills become even more important in teams that come together on a temporary basis (Flin 2004). Those authors point out that, unlike military teams that often train together and work together as a unit for long periods, pilots in commercial aviation often come together with other members of the flight crew on a more temporary basis. The aviation industry has long recognized that problems in non-technical skills, rather than knowledge or flying ability, are significant factors contributing to crashes. They highlight the similarities between aviation and areas in healthcare such as the OR, ICU, and ER and stress how the principles used in crew resource management (CRM) can be applied equally to medicine. They describe how systems were developed to measure non-technical skills in anesthesia (ANTS or the Anesthetists Non-Technical Skills, CARMa or Crisis Avoidance and Resource Management) modeled on the NOTECHS system that had been established for measuring non-technical skills in pilots. Such systems may be used on either videotapes of real OR cases or used on simulations done with teams.
Most studies on non-technical skills in surgery have come from simulated environments (Hull 2012). They point out that there is a high correlation between technical error and teamwork failure.
Two articles in the May 2012 issue of the Annals of Emergency Medicine identify the importance of non-technical skills in emergency department physicians.
Emergency physicians probably have to deal with more interruptions and do more multitasking than physicians in other venues (Flowerdew 2012a). They have to deal with multiple patients simultaneously, some of whom have not even yet arrived at the emergency department. So anticipation, situational awareness, and workload management are crucial non-technical skills for an effective emergency physician. Similarly, communication skills during handoffs are extremely important. In our February 14, 2012 Patient Safety Tip of the Week Handoffs More Than Battle of the Mnemonics we focused on the unique context of handoffs in the ED and discussed the ABC of handover tool for ED handoffs (Farhan 2012). Rather than focusing on just the transfer of information and responsibility for single patients, they focus on the transfer of responsibility of a whole department, the ED, at change of shift. That includes knowledge of all the patients in the ED, prioritization of risks, pending tests and other issues, patient flow and waiting time issues, staffing patterns, equipment issues, planned patient dispositions (admissions, transfers, discharges), and even events taking place in the community that might impact the ED, and sometimes teaching responsibilities.
In the second article by the same group (Flowerdew 2012b) a tool for assessing non-technical skills of emergency physicians was developed and validated. A copy of that tool is available in the article.
The importance of non-technical skills has also been studied for cardiac arrest teams (Anderson 2010). The authors identified some barriers to good team function that were based in non-technical skills. Such barriers included inexperienced leadership, task overload, and hierarchical structure. They recommended training should include structured communication, use of cognitive aids, mutual performance monitoring, and avoidance of task overload.
Assertiveness is often a double-edged sword in team situations. Dominating a team can become dangerous but appropriate assertiveness is important. Communication obviously takes place between and among numerous individuals in settings such as the OR. Not being afraid to buck the authority gradient or hierarchy is critical and assertive communication is a key component of good teamwork. One example of escalating assertive communication is the CUSS tool (Yule 2012):
C Im concerned and need clarification
U I am uncomfortable and dont understand
S Im seriously worried here
Attempts to improve non-technical skills via simulation have had mixed results. Anesthesiology residents (Yee 2005) participated in 3 simulated cases and were videotaped and provided feedback. After the first simulation and feedback there was significant improvement in non-technical skills. But there was no further improvement after subsequent simulated cases. However, a similar trial in practicing anesthesiologists (Morgan 2011) was not successful in improving non-technical skills.
Programs such as the TeamSTEPPS training program (see our May 22, 2007 Patient Safety Tip of the Week More on TeamSTEPPS and our March 2009 Whats New in the Patient Safety World column Surgical Team Training) are very useful at developing non-technical skills that are crucial to good teamwork.
Formal CRM training programs are also good ways to develop non-technical skills. Most studies looking at CRM training have looked only at short-term outcomes. But our January 2010 Whats New in the Patient Safety World column Crew Resource Management Training Produces Sustained Results highlighted a study (Sax et al 2009) that demonstrated improved outcomes that have been sustained over the long run. Outcomes included increased use of preoperative checklists, increased self reporting, more reporting of near misses and environmental conditions, and several measures indicative of a culture of safety.
Many of you have heard the adage Hire for attitudeTrain for Skills. That, of course, means that having in your organization people with good non-technical skills may be more important that having those who have good technical skills but lack the other important traits we have discussed in todays column. But, fortunately, there is hope that even though some of those non-technical skills are innate there may be opportunities to improve them through identification, feedback and training.
Yule S, Paterson-Brown S. Surgeons Non-technical Skills. Surgical Clinics of North America 2012; 92(1): 37-50
Flin R, Maran N. Identifying and training non-technical skills for teams in acute medicine. Qual Saf Health Care 2004; 13(Suppl 1): i80-i84
Hull L, Arora S, Aggarwal R et al. The Impact of Nontechnical Skills on Technical Performance in Surgery: A Systematic Review. J Am Coll Surg 2012; 214(2): 214-230
Flowerdew F, Brown R, Vincent C, Woloshynowych M. Identifying Nontechnical Skills Associated With Safety in the Emergency Department: A Scoping Review of the Literature. Ann Emerg Med 2012; 59(5): 386-394
Farhan M, Brown R, Woloshynowych M, Vincent C. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J 2012; Published Online First: 3 January 2012 http://emj.bmj.com/content/early/2012/01/03/emermed-2011-200199.full.pdf+html?sid=4b3509fa-c354-42cb-a27c-b80721ddeec5
Flowerdew F, Brown R, Vincent C, Woloshynowych M. Development and Validation of a Tool to Assess Emergency Physicians' Nontechnical Skills. Ann Emerg Med 2012; 59(5): 376-385
Andersen PO, Jensen MK, Lippert A, stergaard D. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams. Resuscitation 2010; 81(6): 695-702
Yee B, Naik VN, Joo HS, et al. Nontechnical Skills in Anesthesia Crisis Management with Repeated Exposure to Simulation-based Education. Anesthesiology 2005; 103(2): 241-248
Morgan, Pamela J. MD, FRCPC; Kurrek, Matt M. MD, FRCPC; Bertram, Susan MD, FRCPC; LeBlanc, Vicki PhD; Przybyszewski, Teresa RRT
Nontechnical Skills Assessment After Simulation-Based Continuing Medical Education
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare:
October 2011 - Volume 6 - Issue 5 - pp 255-259
Sax HC, Browne P, Mayewski RJ, et al. Can Aviation-Based Team Training Elicit Sustainable Behavioral Change? Arch Surg. 2009; 144(12): 1133-1137
May 15, 2012
As we have tried to cover more patient safety topics related to ambulatory care we keep coming back to diagnostic error. Note that we try to avoid the term cognitive error that often appears in the literature as synonymous with diagnostic error. But cognitive error implies human error whereas diagnostic error is much more encompassing of the interaction between system-related factors and human-related factors. And well see that system-related errors are just as important in leading to errors that result in adverse patient outcomes. Care in the ambulatory setting differs greatly from that in inpatient and long-term care settings because ambulatory care is typically disseminated in both time and place. That is, the interaction with the typical patient takes place over weeks or months in the outpatient setting whereas it takes place over several days in the hospital. And, whereas in the hospital most of the players are co-located within the walls of the hospital, on the outpatient side the various caregivers are seldom in one location. Add to that the fact that medical record systems on the outpatient side are often not interconnected with each other or with the hospital IT systems. And further add to that patient-level factors. Remember, the patient is captive while an inpatient and cant fail to keep an appointment like they can on the ambulatory side. Also, research has shown that patients are more likely to be compliant with statin therapy (and other medications) when it is begun in a hospital after an acute event (the teachable moment) than they are if it is started in ambulatory care for primary prevention. So ambulatory care presents its own set of barriers and challenges that can enable diagnostic errors.
Weve already done several columns on diagnostic error, including our Patient Safety Tips of the Week for September 28, 2010 Diagnostic Error and November 29, 2011 More on Diagnostic Error (hence todays title Diagnostic Error Chapter 3). But several outstanding resources have become available since our last column in November 2011.
The ECRI Institute put on a great webinar in December 2011 on best practices for preventing missed, delayed, or incorrect diagnoses and makes it available for free on their website (ECRI 2011a). They confirm that diagnostic errors rank second in malpractice claims (after obstetrical events) and stress the importance of breakdowns in communication in most such events. They use case examples to illustrate many of the major factors contributing to diagnostic errors and provide solid recommendations to help minimize the risk of such events.
For missed diagnoses, cancer or cardiovascular diseases predominate. They present a case of missed breast cancer in a patient who had presented with breast pain and discharge and another about a missed colon cancer. Lessons learned include the need to take all symptoms seriously, follow them up to resolution, and consider rare presentations. They highlight the problem of missed appointments and stress documentation issues, including the importance of documenting family history and documenting all the systems reviewed and their findings. They note you should train your staff to stress the importance of cancer screening. They also stress the importance of revisiting diagnosis if a patients symptoms have failed to resolve.
Continuity of care issues are often problematic, particularly in teaching hospital settings. They discuss a case where a patient with a superficial arterial occlusion was seen by 7 different providers over a 5-week period before the correct diagnosis was made. In this case a resident originally focused on the patients prior history of lumbar disc disease. Subsequent residents seeing the patient probably relied on that initial evaluation rather than using their own history and revisiting the diagnosis.
They also provide the classic case of the missed aortic dissection, misdiagnosed as acute coronary syndrome. Avoiding premature closure, where one diagnosis is settled on before others have been adequately excluded, is of paramount importance.
When it comes to test tracking, one of our most frequent topics, they refer back to a webinar they had done in April 2011 (ECRI 2011b). In test tracking it is important to determine who is accountable for following up on test results, making sure the patient is compliant with getting the testing, and documenting all interventions or attempts to intervene.
Especially important is not leaving test results on voicemail. Though that was in the context of critical abnormal test results, that applies equally to all test results. HIPAA issues aside, you may not be able to verify that the patient ever actually heard the voicemail message or understood it. You also should have policies in place dealing with what to do if a patient cannot be reached (such as knowing when to contact police or other parties to help locate the patient).
During follow-up visits it is important to go back and inquire about symptoms discussed on prior visits and ensure they have resolved. Making sure patients keep follow-up visits or attend any referrals is very important. You should always document any communications that take place, even when there is no face-to-face visit.
And what about the rare diagnosis? They note failure to consider a diagnosis is one of the main causes of missed diagnosis. Using clinical decision support tools may be helpful in at least considering unusual or rare diagnoses. A second review of test results may be useful. And always considering the worst case scenario is a good practice.
Engaging the patient is important. Making sure they know why you are ordering a test or making a referral and emphasizing the need for follow-up are important considerations. Documenting such discussions and informed consent discussions are also important. Phone calls, particularly those after hours or on weekends, often go undocumented so having systems in place to capture those conversations are critical. They also provide examples of things you might say to help facilitate patient compliance with testing and referrals and follow-ups.
Another example case involves an on-call physician receiving a call from a patient who had been started on a new antihypertensive medication now complaining of weakness. Three days later the patient had an embolic stroke from atrial fibrillation. Even if the complaints on the phone call were unrelated to the subsequent stroke, the immediate attribution of symptoms to the new medication without subsequent questioning put this physician at-risk for the subsequent events.
The last case was one of a missed cervical cancer in which several issues, including failure to follow-up an inadequate Pap smear, contributed.
A recent paper on diagnostic errors in primary care (Ely 2012) also noted that diagnostic errors were often preceded by common symptoms and common, relatively benign initial diagnoses. The three most common lessons learned in their review were (1) consider diagnosis X in patients presenting with symptom Y (2) look beyond the initial, most obvious diagnosis and (3) be alert to atypical presentations of disease. The authors note how mental shortcuts and cognitive biases such as anchoring, premature closure, and diagnostic momemtum frequently lead to diagnostic errors. Broadening the differential diagnosis and always considering the dont miss diagnoses were important themes. They recommend de-biasing strategies (see Croskerry discussion below) such as diagnostic timeouts and use of checklists, noting that these strategies have still not been well developed with an evidence base.
Pat Croskerry, whose work we highlighted in our November 29, 2011 Patient Safety Tip of the Week More on Diagnostic Error points out a host of reasons that diagnostic error has not been a prime focus of the patient safety movement (Croskerry 2012). He again emphasizes that we spend most of our time in the intuitive rather than the rational decision-making mode. In the intuitive mode failed heuristics and cognitive and affective biases are widespread. He points to numerous studies that have demonstrated most diagnostic errors occur in relation to common, well-known illnesses and thus lack of knowledge is not the most likely cause. He provides a clinical example of a case of missed pulmonary embolism in which both emotional and cognitive biases prevented the clinician from recognizing the correct diagnosis. The gist of his arguments to reduce diagnostic error is therefore to focus on ways to debias or thinking.
Situational awareness (see our May 8, 2012 Patient Safety Tip of the Week Importance of Nontechnical Skills in Healthcare) is also important in avoiding diagnostic errors or delays in diagnosis. While we most often discuss situational awareness in rapidly evolving situations, it is also important in more chronic circumstances and settings. Hardeep Singh and colleagues (Singh 2012a) reviewed a population of patients with colorectal and lung cancers and found errors in about a third of cases of both types of cancer. They applied a framework of situational awareness and noted one of four levels of situational awareness often lacking: information perception, information comprehension, forecasting future events, and choosing the appropriate action based on the above three. An example under information perception might be that a positive fecal occult blood test was missed so a colonoscopy was not scheduled. At the information comprehension level, a positive fecal occult blood test may have been ascribed to other reasons (eg. hemorrhoids). At the forecasting level, a provider failed to foresee that a patient might fail to keep an appointment before the provider left for an extended leave. And under choosing appropriate action, an example was lack of a sense of urgency in responding to a clue like microcytic anemia. The authors discuss some potential interventions that might be helpful, both at the individual provider level and at the system level. One is fostering a sense of dynamic skepticism, a term borrowed from aviation, that is continuous questioning of the validity of previous assumptions based on constantly evaluating incoming data. At the system level, putting data in a format that might better highlight clues may help (eg. putting weights in graphic form so that the EHR might help a provider notice weight loss).
Another recent paper (Zwaan 2012) looked at diagnostic reasoning in five Dutch hospitals. They used the term suboptimal cognitive acts (SCAs) rather than cognitive errors to identify faults in diagnostic reasoning that had a low threshold and correlated these with diagnostic error and patient harm. They found an average of 2.6 SCAs per patient record reviewed and found that SCAs were more frequent in cases with diagnostic error and those with patient harm. However, they did note that in almost 20% of cases with diagnostic error or patient harm, there were no SCAs. They classified SCAs in Reasons taxonomy of unsafe acts and found 62% of SCAs were intended acts, 58% mistakes, and 49% violations. Unintended actions accounted for 26% of SCAs, with 14% being slips and 12% lapses. They found that most SCAs occurred during data gathering stages and in cases where patient harm occurred the SCAs were often related to laboratory testing (including unnecessary testing). Harm, generally, was not severe. The article provides lots of good examples of the SCAs, with examples in each of the Reason taxonomy categories. They also have a discussion of why no harm occurred in some cases despite SCAs.
Another study from the Netherlands (Mamede 2012) looked at diagnostic reasoning in medical students and internal medicine residents. They had previously noted that salient distracting features are a major contributor to diagnostic errors, particularly when in the non-analytic reasoning mode. They showed that reflective reasoning led to significantly more correct diagnoses. Interestingly, students did not benefit from reflective reasoning. The implication is that certain salient features may attract a physicians attention and misdirect the diagnostic reasoning process. Reflective reasoning may help overcome the influence of these distracting features.
Patient-level factors frequently contribute to diagnostic errors as well. Assessment of a patients health literacy is also important since we need to make sure our patients (or their caregivers) understand the importance of the test, the referral, or the treatment.
Identification of diagnostic errors remains problematic for a number of reasons Singh and colleagues (Singh 2012b) used the trigger tool concept in attempt to identify diagnostic errors in primary care practices. Trigger #1 was a primary care visit followed by an unplanned hospitalization within 14 days. Trigger #2 was a primary care visit followed by one or more unplanned visits within 14 days. In charts identified by Trigger #1 the positive predictive value for diagnostic error was 20.9% and for Trigger #2 5.4%. Both were higher than the PPV for control charts (2.1%). Though these are modest values, they are obviously better at identifying charts having diagnostic errors than would be obtained from random chart review, thus constituting a promising methodology for future study of diagnostic error.
As before, there has been little in the way of rigorous evaluation of suggested interventions to minimize diagnostic error. A recent review of over 140 articles in the literature on cognitive interventions (Graber 2012) noted that most had either not been formally tested or have only been tested in artificial settings. A companion article by the same group (Singh 2012c) looked at system-related interventions to reduce cognitive errors and noted a lack of scientific rigor in most studies. In our November 29, 2011 Patient Safety Tip of the Week More on Diagnostic Error we noted an article by Ely and colleagues (Ely 2011) suggesting use of checklists to help avoid diagnostic errors and an article by Schiff and Bates (Schiff 2010) proposing a number of ways that electronic health records might be used to improve diagnostic accuracy and prevent diagnostic error.
Given the rapid increase in the number of publications on diagnostic error in recent years, you can expect some of the potential interventions noted above will begin to be tested in more rigorous studies in the near future.
Some of our prior Patient Safety Tips of the Week on diagnostic error:
ECRI Institute. Best Practices For Preventing Missed, Delayed, or Incorrect Diagnoses (webinar). December 2011.
ECRI Institute Webinar: Getting on the Right Track: Tracking Test Results, No-Show Appointments, and Hospital Visits.
April 13 & 14, 2011
Ely JW, Kaldjian LC, D'Alessandro DM. Diagnostic Errors in Primary Care: Lessons Learned. J Am Board Fam Med 2012; 25: 87-97
Croskerry P. Perspectives on Diagnostic Failure and Patient Safety. Healthcare Quarterly 2012; 15(Special Issue): 50-56
Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf 2012; 21: 30-38 Published Online First: 2 September 2011 doi:10.1136/bmjqs-2011-000310
Zwaan L, Thijs A, Wagner C, et al. Relating Faults in Diagnostic Reasoning With Diagnostic Errors and Patient Harm. Academic Medicine 2012; 87(2): 149-156, February 2012
MamedeS, Splinter TAW, van Gog T, et al. Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. BMJ Qual Saf 2012; 21:295-300 doi:10.1136/bmjqs-2011-000518
Singh H, Giardina TD, Forjuoh SN, et al. Electronic health record-based surveillance of diagnostic errors in primary care. BMJ Qual Saf 2012; 21: 93-100 Published Online First: 13 October 2011 doi:10.1136/bmjqs-2011-000304
Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf 2012; published online ahead of print 27 April 2012 doi:10.1136/bmjqs-2011-000149
Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf 2012; 21: 160-170 Published Online First: 30 November 2011 doi:10.1136/bmjqs-2011-000150
Ely JW, Graber M, Croskerry P. Checklists to reduce diagnostic errors. Academic Medicine 2011; 86(3): 307-313
Schiff GD, Bates DW. Can Electronic Clinical Documentation Help Prevent Diagnostic Errors? NEJM 2010; 362(12): 1066-1069
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
We have been advocates for screening for obstructive sleep apnea (OSA) preoperatively (see links to prior columns listed below). This month there are 2 new papers on this topic from Frances Chung and her group in Toronto. One is further validation of the utility of the STOP-Bang questionnaire in predicting OSA. The other is one that looked at simple nocturnal oximetry and found that an oxygen desaturation index (ODI) >10 would predict most cases of moderate and severe OSA (though not good at picking up central apnea). Since delaying surgery to get formal polysomnographic studies might not be feasible in many cases, having alternative means of identifying high-risk patients is very desirable.
The first paper (Chung 2012a) extended their previous work on using the STOP-Bang questionnaire to predict OSA. 746 patients scheduled for inpatient surgery underwent both the STOP-Bang questionnaire and polysomnography (lab-based or home-based). Overall, OSA was present in 68.4% of patients (note that it is highly likely that patients having symptoms of OSA may have been more likely to consent to this study). They then looked at the sensitivities and specificities and positive and negative predictive values of various STOP-Bang scores to predict moderate or severe OSA and concluded that a STOP-Bang score of 5-8 identified a population with a high probability of moderate/severe OSA.
In the second study (Chung 2012b) 475 patients scheduled for inpatient surgery underwent home-base polysomnography and nocturnal oximetry with a wristwatch-based oximeter. Compared to those patients having an oxygen desaturation index (ODI) less than 5, those with an ODI greater than 5 had a significant increase in frequency of sleep disordered breathing. Using a cutoff ODI >10 had a sensitivity of 93% to detect moderate or severe OSA. The nocturnal ODI was not as sensitive in identifying central apnea.
Taking the two studies together leads to a potential strategy for identifying patients with OSA preoperatively without having to do a formal polysomnogram, that is using the STOP-Bang questionnaire followed by nocturnal oximetry in appropriate cases.
Though we dont know whether CPAP is effective perioperatively in this population (the only study showed no benefit), knowing that someone has OSA has perioperative implications in airway management, opiate and other drug selection, post-op monitoring, pulmonary complications, overall complications and LOS. A previous study (Kaw 2012) found that patients with OSA undergoing cardiac surgery were almost 7 times more likely to have overall complications, 8 times more likely to have postoperative hypoxemia, and over 4 times more likely to require transfer to an ICU. They also had longer lengths of stay. Another study (Memtsoudis 2011) had also shown about a 5-fold increase in respiratory failure in patients with OSA undergoing noncardiac surgery. The latter study showed patients with OSA developed pulmonary complications more frequently than their matched controls after both orthopedic and general surgical procedures.
However, what we need to do now is demonstrate that outcomes can be improved by doing such preoperative screening and then implementing care management programs for this high-risk population.
A recent review of sleep disorders in hospitalized patients (Venkateshiah 2012) describes the physiology of sleep disturbances in this population and the factors contributing to disturbed sleep in the hospital. It also summarizes the ASA recommendations for perioperative management of OSA. Pain is the most common cause of disturbed sleep. One of the key occurrences in the immediate post-surgical period is a suppression of REM (rapid eye movement) sleep. This may be related to factors such as catecholamine levels and treatment with opioids. Then, on the second and third post-op days there is a REM rebound. During this period there is a significant increase in episodic oxygen desaturations due to disordered breathing.
Venkateshiah and Collop go on to summarize the American Society of Anesthesiologists (ASA) practice guidelines for the perioperative management of patients with OSA (ASA 2006). Like other reviews of the perioperative management of patients with OSA (Chung 2008, Adesanya 2010) they readily admit there is a paucity of evidence-based recommendations for care of surgical patients with suspected or known OSA.
There are obviously many reasons to identify patients preoperatively who are at high risk for OSA. Such patients are at greater risk for difficult intubation and are at risk for multiple post-operative complications. Anesthesiologists would like to use local anesthesia or peripheral nerve blocks where appropriate or otherwise use short-acting anesthetic agents in such patients and completely reverse the effects of neuromuscular blocking agents. Avoidance of the supine position as much as possible is recommended since some OSA is position-dependent.
Monitoring of the patient with OSA is obviously a key consideration. But Venkateshiah and Collop are quick to point out that there is a lack of an evidence base that monitoring with either pulse oximetry or capnography improves outcomes in this population.
Our February 22, 2011 Patient Safety Tip of the Week Rethinking Alarms highlighted an excellent study by Lynn and Curry (Lynn 2011) who describe 3 patterns of unexpected in-hospital deaths and demonstrate the problems with threshold-based alarms (almost all currently used alarm systems use threshold-based principles) in detecting early deterioration. Indeed, they posit that threshold-based alarms themselves often cause us to miss signs of early deterioration. Even systems using continuous pulse oximetry and end-tidal CO2 monitoring may fail to adequately identify these patients. Nevertheless, we recommend monitoring with oximetry, capnography, and a rate/apnea monitor post-operatively. And while the first 12-hours post-operatively is a vulnerable period, the REM rebound and REM-associated hypoxemic events may increase 3-fold on the second and third postoperative nights, with associated risk of complications. Thus, monitoring should not be stopped before this period
Similarly, most of the recommendations for management of OSA in the post-op patient are consensus recommendations, as there has been a paucity of evidence. So most recommendations remain based on consensus opinion.
In patients with known OSA who are on CPAP at home, it is usually recommended that you have the patient bring in their CPAP machine from home. But in patients with suspected OSA or just recently diagnosed OSA who have not yet been on CPAP the effectiveness of CPAP in the hospital has not been demonstrated. In our November 22, 2011 Patient Safety Tip of the Week Perioperative Management of Sleep Apnea Disappointing we noted one of the few randomized controlled studies of surgical patients deemed at high risk of OSA had disappointing results (OGorman 2011). That study showed that autotitrating positive airway pressure (APAP) failed to prevent obstructive apnea in surgical patients deemed high risk for the disorder. They did find that patients deemed to be at high risk for OSA had longer lengths of stay and more complications than those deemed to be at low risk. They randomized 85 patients deemed at high risk for OSA to standard postoperative care or standard care plus APAP but found no significant difference in LOS or complications between the two groups. Admittedly, the number of patients studied was small and further research is needed. But it leaves one more gap of evidence-based recommendations.
Many of the recommendations are to minimize the use of opioids. These would include using regional analgesic techniques or use of NSAIDs where possible. Most also recommend avoiding continuous background opioid infusions in patients on PCA pumps.
The guidelines recommend continuous oxygen supplementation until the patient has been shown to maintain adequate baseline oxygen saturation on room air. When to stop oxygem supplementation is less clear. Weve cautioned on numerous occasions the possibility that oxygen supplementation in patients receiving systemic opioids may actually mask impending respiratory failure.
So, once again, we recommend you consider setting up a screening program for likely OSA prior to scheduled surgery. The STOP-Bang questionnaire is easy to administer in a few minutes and could be done at the time of surgical booking or other time the surgical team contacts the patient. Having a clinical guideline for dealing with those who score high on the STOP-Bang would be wise, keeping in mind that most of those recommendations will be consensus-based rather than evidence-based.
Our prior columns on obstructive sleep apnea in the perioperative period:
Patient Safety Tips of the Week:
June 10, 2008 Monitoring the Postoperative COPD Patient
August 18, 2009 Obstructive Sleep Apnea in the Perioperative Period
August 17, 2010 Preoperative Consultation Time to Change
July 13, 2010 Postoperative Opioid-Induced Respiratory Depression
February 22, 2011 Rethinking Alarms
November 22, 2011 Perioperative Management of Sleep Apnea Disappointing
Whats New in the Patient Safety World columns:
Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. British Journal of Anaesthesia 2012; 108 (5): 76875 (2012)
Chung F, Liao P, Elsaid H, et al. Oxygen Desaturation Index from Nocturnal Oximetry: A Sensitive and Specific Tool to Detect Sleep-Disordered Breathing in Surgical Patients. Anesthesia & Analgesia 2012; 114(5): 993-1000 Published online before print February 24, 2012
Venkateshiah SB, Collop NA. Sleep and Sleep Disorders in the Hospital. CHEST 2012; 141(5): 1337-1345
American Society of Anesthesiologists. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. A Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2006; 104: 108193
Chung SA, Yuan H, Chung F. A Systemic Review of Obstructive Sleep Apnea and Its Implications for Anesthesiologists. Anesthesia & Analgesia 2008; 107(5): 1543-1563
Adesanya AO, Lee W, Greilich NB, Joshi GP. Perioperative Management of Obstructive Sleep Apnea. Chest December 2010; 138(6): 1489-1498
Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11 February 2011)
O'Gorman S, Horlocker T, Huddleston J, et al. Does Self-Titrating CPAP Therapy Improve Postoperative Outcome in Patients at Risk for Obstructive Sleep Apnea Syndrome? A Randomized Controlled Clinical Trial. Chest 2011; 140: 4 Meeting Abstracts 1071A; doi:10.1378/chest.1119434
also reported in: Harrison L. Postop APAP Fails in High-Risk Sleep Apnea Patients. Medscape Medical News. November 3, 2011
May 29, 2012
Falls, Fractures, and Fatalities
One of the purposes of the ongoing switch to ICD-10 coding is to provide much greater detail about medical illnesses and issues from administrative databases. The US ICD-10 CM has some 68,000 codes and the ICD-10 PCS, a procedure code system not used by other countries, contains 76,000 codes. One of the areas in which ICD-10 coding provides considerably more detail that ICD-9 coding is related to cause of death. Hu and Baker (Hu 2012) recently analyzed ICD-10 coding and demonstrated a significant relationship between falls and death. In the old system we might sign a death certificate with a cause of death something like pneumonia or pulmonary embolism and there would be no way to show that the patient really suffered these events after being hospitalized for a fall that resulted in a hip fracture. They found in seniors a 42% increase in falls as a cause of death between 1999 (when the ICD-10 was first implemented in their study) and 2007. They are quick to point out that this likely reflects an improvement in coding rather than an actual increase in falls leading to death. Nevertheless, it highlights how important falls are in relation to people dying.
Weve discussed in previous columns fall risk and prevention on med/surg units and rehab units (see our October 7, 2008 Patient Safety Tip of the Week Lessons from Falls....from Rehab Medicine). Weve also stressed the multiple substantial risks that occur in the radiology suite. One of those risks in radiology is that of patients falling from tables or gurneys or when they try to walk to a bathroom (January 2010 Whats New in the Patient Safety World column Falls in the Radiology Suite). Thats the reason we have strongly recommended that one of the items on your Ticket to Ride (or other structured tool you use to communicate various risks and concerns when you send a patient off to another part of the hospital) needs to be a flag for fall risk. Note also that some of the other items youll put on your Ticket to Ride (such as altered mental status, certain medications, etc.) may also infer an increased risk of falling (see our November 18, 2008 Patient Safety Tip of the Week Ticket to Ride: Checklist, Form, or Decision Scorecard?). And, as a recent malpractice claim alleged (Christoffersen 2012) falls off any table where procedures being done are possible, particularly when patients get medicated for the procedure.
Another area where attention to fall risk tends to be less than optimal is the behavioral health unit. Yet the risks on such units may be as great or greater than on even med/surg units or rehab units. Fortunately the VA National Patient Safety Center, which does a great job of aggregating lessons learned from RCAs across the VA system, recently put together such lessons learned as they pertain to falls on behavioral health units (Lee 2012). They noted that falls most often occurred as patients were getting up from bed or a chair or wheelchair, walking/running, bathroom-related, or behavior-related. The most common root causes they identified were environmental hazards, poor communication of fall risk, lack of suitable equipment, and a need to improve the system of falls assessment.
Lee et al. point out that patients on behavioral health units are at risk for falls for a number of reasons. Most importantly, they are on a variety of medications that may increase the fall risk (antipsychotics, antidepressants, sedative/hypnotics, and others). Some may be confused or agitated. Others may have impaired gait or balance, sometimes as a result of extrapyramidal side effects of their medications. Many of the medications cause orthostatic hypotension. The elderly patient on the behavioral health unit is especially at risk for falls with injury. They also note that sometimes behavioral health units restrict use of canes or other devices that could assist ambulation because such might also be used as weapons.
The authors have numerous recommendations for ways to improve fall prevention on such units. One is assessing the environmental risks, using a checklist. Quite frankly wed like to see a checklist-like audit tool for assessing all the risks they have pointed out, not just the environmental ones. This topic is also a good one for a FMEA (failure mode and effects analysis) if you have a behavioral health unit.
Lastly, many of you are familiar with the QFracture algorithms. These were developed and validated to provide a prediction of the risk of osteoporotic fracture or hip fracture in primary care settings based upon data elements easily obtainable from the medical record or directly from the patient without the need to rely on special testing. Though the original algorithms worked well, a guidance from NICE (National Institute for Health and Clinical Excellence) had suggested additional risk variables might improve the tools. So multiple new potential variables were considered in a derivation population to develop new algorithms and validated in separate populations (Hippisley-Cox 2012). While many of the variables that proved to have predictive ability do impact osteroporosis per se, many probably exert their influence by increasing the risk of falls. We suspect that to be the case for variables such as diabetes and Parkinsons disease. All classes of antidepressants increased the fracture risk. Epilepsy or treatment with anticonvulsants also increased the risk (not just those anticonvulsants known to promote osteoporosis). The updated QFracture-2012 risk calculator is available online and allows you to predict the fracture risk over defined periods of time (1-10 years).
Hu G, Baker SP. An Explanation for the Recent Increase in the Fall Death Rate Among Older Americans: A Subgroup Analysis. Public Health Reports 2012; 275-281
Christoffersen J. Woman sues hospital over fall off operating table. Associated Press May 22, 2012
Lee A, Mills PD, Watts BV. Using root cause analysis to reduce falls with injury in the psychiatric unit. General Hospital Psychiatry 2012; 34(3): 304-311
Hippisley-Cox J, Coupland C. Derivation and validation of updated QFracture algorithm to predict risk of osteoporotic fracture in primary care in the United Kingdom: prospective open cohort study. BMJ 2012; 344:e3427 doi: 10.1136/bmj.e3427 (Published 22 May 2012)
QFracture-2012 risk calculator: http://qfracture.org
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
In our April 16, 2007 Tip of the Week Falls With Injury we discussed falls with injury, with particular emphasis on what the first responder to a fall needs to do. We pointed out that the responder needs not only to assess the patient for injuries but also to do an assessment of the reason for the fall. Having a checklist to help the medical responder is a good way to ensure that the injuries are attended to and the cause of the fall is considered.
But the medical provider responding also needs to assess the patient for injuries related to the fall. That includes looking for lacerations, soft tissue injuries, internal injuries and head injuries. In our July 17, 2007 Patient Safety Tip of the Week Falls in Patients on Coumadin or Heparin or Other Anticoagulants we highlighted the problem of delayed hemorrhage after falls in patients on anticoagulants. Specifically we discussed the patient who falls and has minor head trauma, has a negative CT scan of the head, and then later develops a subdural hematoma (or other intracranial hemorrhage). The example we gave was an elderly patient with a cardiac condition on full-dose heparinization while an inpatient who had an unwitnessed fall in the hospital one evening. He did not lose consciousness and was alert and fully oriented when the medical resident examined him after the fall. He had a mild ecchymosis on his right forehead but no focal neurological signs and no evidence of trauma elsewhere on the body. Because the patient was fully anticoagulated, the resident ordered an emergency head CT scan, which was normal. No changes were made in his heparin regimen. The following morning the patient was more somnolent than usual and a repeat CT scan showed a sizeable subdural hematoma that required surgical evacuation.
Many good clinical decision rules for minor head injury already used in your emergency rooms, such as the Canadian CT Head Rule (Stiell 2001), do not apply to patients who have a bleeding disorder or who are on anticoagulants.
So the timing of a CT scan may be important in the patient who is anticoagulated. The accumulation of a subdural hematoma after minor head trauma may be slow in a patient on anticoagulants. But the optimal time to scan such patients remains unclear.
Some new studies from the emergency medicine literature shed some light on the risks of delayed hemorrhage after minor head trauma in patients taking anticoagulants. A study from Italy (Menditto 2012) reported on implementation of recommendations from the 2002 guideline from the European Federation of Neurological Societies. That protocol called for an initial CT scan on anticoagulated patients with minor head trauma, admission for 24 hours of close neurologic observation, then a second CT scan before discharge.
Menditto et al. enrolled 97 consecutive patients on anticoagulation who had minor head trauma and had an initial negative CT scan and observed them for 24 hours. 10 refused a second CT scan and were discharged and did well. Of the remaining 87 patients 5 had intracranial hemorrhage on their second CT scan. In addition, 2 patients who were discharged after two negative CT scans returned within 8 days with subdural hematomas.
The biggest predictor of delayed intracranial hemorrhage was an INR > 3.
The second study (Nishijima 2012) looked at over 1000 patients who were on either warfarin or clopidogrel and had minor head trauma. The prevalence of intracranial hemorrhage on immediate CT scan was 12% in those on clopidogrel and 5.1% in those on warfarin. However, none of the clopidogrel patients developed delayed intracranial bleeding compared to 0.6% of patients on warfarin. They suspect one reason for the higher prevalence of intracranial bleeding in the clopidogrel patients may have been more frequent aspirin use compared to those on warfarin. They conclude that since the overall risk of delayed intracranial hemorrhage in patients on warfarin or clopidogrel is low, discharge of such patients after a negative CT scan is reasonable but appropriate instructions regarding possible delayed bleeding are required. However, it should be noted that 2 of the 4 patients on warfarin with delayed intracranial hemorrhage died as the result of massive intracranial hemorrhages within one week.
A previous study (Kaen 2010), using basically the same guidelines as the Menditto study, found only 2 cases of delayed intracranial hemorrhage in 137 consecutive mostly elderly patients on either warfarin or heparin who had minor head trauma. Neither needed neurosurgical intervention. Both were also on antiplatelet agents and both had lost consciousness at the time of head trauma. They provided references to the case reports and small case series in the literature of anticoagulated patients with delayed intracranial hemoorhage after minor head trauma and noted that neurological deterioration in most such cases takes place in the first few hours after the injury. They argued that the need for the control (i.e. the second) CT scan before discharge is unnecessary in patients who remain neurologically intact.
Note that none of these studies answers the question What is the optimal timing of imaging in anticoagulated patients with minor head trauma?. When Menditto et al. put their series together they excluded 16 patients who had intracranial hemorrhage on the initial CT scan. We are not told how those patients did clinically. But one might make an argument in this patient population, assuming they will indeed get close neurological checks while under observation, to simply hold off on the first CT scan until 24 hours if they are initially neurologically intact. That might be more cost-effective. But keep in mind that deterioration can take place rapidly. The editorial accompanying the Mendtto study (Li 2012) describes a case in which such a patient went from neurologically normal with a normal CT scan to having a massive subdural hematoma requiring surgical evacuation in a 3-hour time span.
So we also emphasize the need for good instructions for the patient (and perhaps more importantly for the caregivers) when such patients are to be discharged. The major initial symptoms and signs of subdural hematomas are usually related to changes in the level of consciousness or cognition rather than focal neurological signs. These can be subtle. Thats why we previously warned in our July 17, 2007 Patient Safety Tip of the Week Falls in Patients on Coumadin or Heparin or Other Anticoagulants that the neuro checks must be carried out as ordered. Weve often seen in that past that there is a tendency for neuro checks to be overlooked when the patient is asleep which is exactly when neuro checks are most important!
Note also that none of the studies includes patients on the new generation of oral anticoagulants that have just begun being used in the last year or so. Also we suspect the same may apply to bleeding in other spaces in patients fully anticoagulated. A good example is retroperitoneal bleeding, which may present with no signs until a drop in hemoglobin is found or flank ecchymoses are noted.
So when you put together your checklist for the medical provider who responds to a hospitalized patient with a fall, make sure you include some guidance on what to do in the patient who is anticoagulated.
Stiell IG, Wells GA, Vandemheen K, et al. for the CCC Study Group. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357: 139196
Menditto VG, Lucci M, Polonara S, Pomponio G, et al. Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol. Ann Emerg Med 2012; 59(6): 451-455
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, et al. Immediate and Delayed Traumatic Intracranial Hemorrhage in Patients With Head Trauma and Preinjury Warfarin or Clopidogrel Use. Ann Emerg Med 2012; 59(6): 460-468
Kaen A, Jimenez-Roldan L, Arrese I, et al. The Value of Sequential Computed Tomography Scanning in Anticoagulated Patients Suffering From Minor Head Injury.
Journal of Trauma-Injury Infection & Critical Care 2012; 68(4): 895-898
Li J. Admit All Anticoagulated Head-Injured Patients? A Million Dollars Versus Your Dime. You Make the Call. Ann Emerg Med 2012; 59(6): 457-459
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
Each year the California Department of Public Health (CDPH) issues reports detailing fines levied against California facilities. We look for them each year, not because they identify hospitals or note fines, but rather because they usually provide root cause analyses that contain very valuable lessons.
Last year we found very helpful lessons learned about infant abduction (see our December 20, 2011 Patient Safety Tip of the Week Infant Abduction) and safety issues related to fentanyl patches (see our September 13, 2011 Patient Safety Tip of the Week Do You Use Fentanyl Transdermal Patches Safely?).
This years group includes 5 instances of retained foreign bodies and each case brings unique aspects that should be important to all facilities. They illustrate several very interesting ways in which foreign bodies get into body cavities and elude detection. Well bet your policy on preventing retention of foreign bodies probably does not address all these!
When you read the RCAs you see many of the predisposing factors previously identified by Gawande et al. (Gawande 2003) or the Pennsylvania Patient Safety Authority (PPSA 2009). These, of course, include such risk factors as:
But some surprising circumstances contributed to the CDPH cases. In one, a Kerlix gauze bandage that had been applied to a wound preoperatively may have contributed to a false correct sponge count. In another a non-radiopaque towel (typical blue towel often used on mayo stands, etc.) got into the operative field and was not accounted for. In yet another a cautery tip was unaccounted for. And in yet another a sponge that had been soaked in local anesthetic in attempt to facilitate wound analgesia was retained. So these are not your usual suspects!
So collectively there are several valuable lessons learned in these RCAs regarding prevention of retained foreign bodies:
In the plans of correction, when policies were revised the facilities ensured inservicing of all appropriate personnel, added such education to initial orientation and annual inservicing/competency assessments, and put in place plans to audit the processes.
While sponges remain the most commonly retained foreign objects, there are more reports of things like displaced or broken parts of equipment or devices. The cautery tip noted above is one such example. Such fragments may migrate or embolize. They may also heat up during MRIs and cause tissue damage.
Most facilities have probably modeled their policies on prevention of RFOs on the AORN (Association of periOperative Registered Nurses) guidelines (Goldberg 2012). In addition to the AORN guidelines on preventing retained foreign objects, there are other extremely valuble resources out there. The NoThing Left Behind campaign is a long-running national surgical patient safety project focused on preventing RFOs (known as RSIs or retained surgical items in their parlance). Their resources include an outstanding comprehensive Preventing Retained Surgical Items Policy (Gibbs 2011) that can be modified for individual facility use. It nicely describes the roles and responsibilities of all the relevant parties nurses and surgical techs, surgeons, anesthesiologists, radiology technicians, and radiologists.
The NoThing Left Behind policy has some very good discussions about details of individual components of the policy. We noted above that one of the CDPH plans of correction recommended use of red medical waste bags for dressings or other items are removed prior to opening. The NoThing Left Behind policy has a good discussion of how bloody sponges may escape detection if they are in a red medical waste bag (or how white unused sponges can be missed in white bags). This policy stresses use of clear bags so the staff can easily see what is inside. They note that it is okay to put those sponges in non-red bags because that is only temporary storage. Ultimately, for disposal, they need to be put in red medical waste bags. But during the procedure the clear bags are preferred.
The NoThing Left Behind policy also has a good discussion on the color of towels. It notes that all cotton gauze disposables placed in the patient will be white surgical sponges or white radiopaque towels (and may contain a separate identifiable label or tag). White radiopaque towels are easier to separate from blue or green drape towels (which may not be radiopaque). Perhaps this might have prevented one of the events in the CDPH report. Ensuring you have radiopaque white towels available so your surgeons do not grab a non-radiopaque blue or green towel is important.
The NoThing Left Behind policy also does not like surgeons doing a sweep. Rather they make the distinction that the methodical wound exam (MWE) relies on two important sensory modalities sight and touch. They note that looking requires active thought, visualization of the item being sought, and focused attention. They point out that the MWE occurs at a natural pause in the operation and is not a time out. The MWE should be done in every case and should not just include the operative site because sponges placed under retractors might be missed. The MWE should be done in every case, not just when told something is missing. The objective of the MWE is to remove all the items so that nurses can perform the closing count. So the MWE is done before the closing count.
Existing guidelines all stress that the count is not the only important thing. Because the count may be correct in 88% of cases of retained surgical items, it remains critical that the surgeon perform a thorough methodical wound exam. Discrepancies in the surgical count are very common (Greenberg 2008), occurring in one of every 8 cases. They found an average of 16.6 counting episodes in 148 general surgery cases and each count averaged 8.6 minutes. In 59% of the discrepancies they found the missing item, thereby avoiding a potential RFO. Such discrepancies took, on average, 13 minutes to resolve. Discrepancies were 3 times more frequent in cases where personnel changed.
So manual counts remain important and are still key to avoiding retained foreign objects. Nevertheless, the fact that counts may still be erroneous simply shows the importance of human factors in such incidents. Hence, the continued search for technological solutions, such as use of RFID technology, barcoding, etc.
California Department of Public Health (CDPH). CDPH Issues Penalties to 13 Hospitals.
Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained foreign bodies after surgery. N Eng J Med 2003; 348(3): 229-35
Pennsylvania Patient Safety Authority (PPSA). Beyond the Count: Preventing the Retention of Foreign Objects.Pa Patient Saf Advis 2009; 6(2): 39-45
Goldberg JL, Feldman DL. Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal 2012; 95(2): 205-219
NoThing Left Behind Campaign.
Gibbs VC. POLICY: NoThing Left Behind: Prevention of Retained Surgical Items Multistakeholder Policy. NoThing Left Behind. February 2011
Greenberg CC, Regenbogen SE, Lipsitz SR, et al. The Frequency and Significance of Discrepancies in the Surgical Count. Ann Surg 2008; 248(2): 337-341
June 19, 2012
More Problems with Faxed Orders
Sometimes when we come to a hospital well wager a friendly bet that we will find certain things (we only bet on things we know are sure winners!). One of those is that we will find alarms that have either been disabled or had their volume altered to make them poorly audible or their parameters have been set so wide that they are unlikely to alarm for important occurrences. Another is that we will find several risk factors for patient suicide. And a third is that we will find examples of problems related to sending or receiving faxed orders or other patient-related material.
On multiple occasions we have noted problems related to faxed orders. The one we have mentioned most often is the missed decimal point (where lines or smudge during fax transmission and printing obscures a decimal point) and the patient receives a 10x overdose of the medication. (In our September 9, 2008 Patient Safety Tip of the Week Less is More.and Do You Really Need that Decimal? we cautioned against even using a decimal point when the fraction following the decimal point is clinically irrelevant because that decimal point may be overlooked, especially in faxed orders.) The opposite, of course, may also occur where a smudge on the fax looks like a decimal point (the phantom decimal point) so the patient receives one-tenth the intended amount.
But weve also mentioned the case where 2 sheets put into a fax machine stick together and thus only one sheet gets transmitted (see our January 18, 2011 Patient Safety Tip of the Week More on Medication Errors in Long-Term Care where we cited such an example from ISMP 2010). Unless you have a cover fax sheet that says 3 pages (cover sheet plus 2 others) the receiving party may not realize that they are missing a page.
Weve also seen cases where faxes on multiple patients are sent out at the same time and the receiving party does not recognize that the second sheet is actually for a different patient (see our January 18, 2011 Patient Safety Tip of the Week More on Medication Errors in Long-Term Care).
Just as with handwritten orders, on a faxed order with a drug ending in the letter L if there is insufficient space between the L and the next number, the receiver may think the L is actually a 1 (one) and give a dose 10 times too high. And dangerous abbreviations may show up even more frequently on faxed orders than orders written on-site because the provider is more likely to have access to the do not use abbreviation list when on-site.
Another mistake is when a person faxes documents that have information on both sides and does not realize that only one side of each page is being faxed.
And remember when you are sending a fax that some elements (eg. text in a different color) may fail to be seen when transmitted. Or that highlighted items (eg. items you tied to stress with a yellow highlighter) may appear blacked out on the received fax! (Reminds me of the time in college when I asked a friend to send me his notes from a class I had missed so I could study for a test the next day. He faxed them and all the important stuff was blacked out!!!).
And one of the most egregious errors of all faxing to the wrong phone number (the misdirected fax). Ever get a call from the local supermarket that you faxed them a sheet with PHI on it? Your HIPAA compliance officer and risk manager will turn gray when that call comes in! See the discussion at the end of this column.
Now ISMP Canada (ISMP Canada 2012) has come up with a new fax error the truncation error. They provide a great example of a faxed order for dalteparin where the da gets cut off in the fax and the lt looks like an H on the fax, resulting in what clearly looks like an order for Heparin. Click on the link above and youll see both the faxed prescription and the original.
Note that prescription has lots of other bad errors on it. It uses the do-not-use abbreviation U (for units) as well as 2 other abbreviations that should be avoided (SQ for subcutaneous and QD for once daily). It has a different dose written above and crossed out. And it does not have listed the indication for the drug. It also has an illegible word following the QD (is it nitely? or is it a providers signature?). And there is nothing on the prescription to indicate the duration of therapy, amount to be dispensed, whether it should be refilled, etc. Who would have thought one prescription could be used as a primer for medication errors!
ISMP Canada notes the importance of reviewing copies of the fax you send or the one you receive. For instance, in the case given one might have noticed that the name of the hospital was also truncated, which might have been a clue that the medication name was truncated. They also note in the example given that the dosing frequency would have been unusual for heparin (it is usually given twice daily or three times daily rather than once daily), perhaps being another clue to the receiver that there was an error. They also note that including both the generic and brand names on the prescription would have provided another clue to the error. They note the importance of engaging the patient to be on the lookout for errors as well.
ISMP Canada lists multiple good recommendations for dealing with faxed orders in their alert. Well add some of our own recommendations:
You should have an educational program for all your staff involved in sending and receiving faxed orders (nurses, physicians, clerical staff, etc.). Remember, telling stories about real-life cases where such errors led to bad outcomes is much more effective than just telling them facts and statistics. Tell them one of the stories about a patient getting a 10-fold overdose or the one where a patient got 26 medications (13 of her own and 13 from the sheet faxed in the same batch on a different patient as in our January 18, 2011 Patient Safety Tip of the Week More on Medication Errors in Long-Term Care).
And dont forget that faxing errors dont just apply to medication orders. Most of the same concerns apply to any patient related material that may be faxed.
There are numerous examples of misdirected fax transmissions containing personal health information. These are often one-time errors but amazingly there are numerous examples in the media of continued recurrences over long periods of time. In one instance (ANewsVanIsland 2011) a person has received at least one such fax per week for over 10 years!!! That persons phone number was one digit different than the fax number for a medical clinic. Think of all the times you have dialed the wrong phone number and how easy that would be to do when sending a fax.
One of the typical recommendations for avoiding staff keying in the wrong fax number is to use pre-programmed fax numbers. However, that practice has its own set of unintended consequences in that those fax numbers need to be up to date. Weve seen faxes sent to old fax numbers after a physician has moved to a new office and even faxes sent to physicians who have been deceased for four years! And hospital computer systems often have the wrong physician listed as primary care physician, often leading to faxes being sent to the wrong PCP.
And often not mentioned is the fact that copies of what you copied or faxed may remain in the memory or hard drive of your fax machine. We remember a situation where the local police department donated some old fax machines to charity and confidential police records were found in the memory of those machines!
ISMP (Institute for Safe Medication Practices). Order scanning systems (and fax machines) may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety Alert (Nurse Advise-ERR) 2010; 8(11): 1-2
ISMP Canada. ALERT: Medication Mix-up with a Faxed Prescription. ISMP Canada Safety Bulletin 2012; 12(6): 1-3 June 5, 2012
ANewsVanIsland. Medical Records Shared with Roofer. Mar 1, 2011
Davis, Nancy, et al.. "Facsimile Transmission of Health Information." (AHIMA Practice Brief, updated August 2006).
Demster B. HIMSS Privacy and Security Toolkit. Managing Information Privacy & Security in Healthcare. Communication Tools. January 2007
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
When we were involved in a CPOE implementation in 2008 we speculated that wrong patient errors would be more likely to occur via CPOE than conventional written orders (see our May 20, 2008 Patient Safety Tip of the Week “CPOE Unintended Consequences: Are Wrong Patient Errors More Common?”). We discussed the need to clearly identify patients on all order entry screens. Then in our January 12, 2010 Patient Safety Tip of the Week “Patient Photos in Patient Safety” we discussed patient photographs as potential tools in patient safety as a concept that had attracted surprisingly little attention to date. We’ve often thought that inclusion of patient photographs would be a logical tool to use in avoiding wrong patient surgeries or mixups in medication administration. And we were surprised to see that many hospital electronic medical record programs lacked standardized fields for such photographs.
In that column we did note some programs that successfully used patient photographs to reduce the risk of patient misidentification during medication administration (AHRQ Health Care Innovations Exchange). But there have been few other published accounts of use of photographs in the patient safety literature.
Recently, Children’s Hospital of Colorado published results of their successful implementation of patient photographs to reduce CPOE errors (Hyman 2012). Beginning with a nice review of the literature on patient-note mismatches, they implemented tools to help avoid such mismatches during CPOE. First they modified their CPOE workflow to include a verification screen asking the provider to verify that this is the patient on whom he/she intends to enter orders. They then began taking photographs of patients at admission or registration and including these on the above noted verification screen. They found a dramatic reduction in the number of events of actual ordering on the wrong patient or near-misses. And when such events or near-misses did occur, it was usually in charts that did not have a photograph of the patient. While they could not separate out the impact of the verification screen from that of the photograph, they felt that the photographs played a large role in reducing the number of orders placed in the records of wrong patients.
They note that, unlike other CPOE alerts that have a high likelihood of being ignored, the presence of the large centrally placed photograph is effective in capturing the attention of the CPOE user. They do note that photographs have limitations, particularly for newborns and when pictures are poorly exposed. And they note that photographs need to be updated at appropriate times.
There are, of course, other advantages to using patient photographs in healthcare (aside from those that are used for clinical activities such as tracking wound healing, etc.). In our December 2008 What’s New in the Patient Safety World “Patient Photographs Improve Radiologists’ Performance” we noted a paper presented at the Radiological Society of North America’s annual meeting (RSNA 2008) showing that inclusion of photographs of patients improved accuracy of radiologists’ reports. Putting a photograph of the patient aside their images on a PAC screen resulted not only in the radiologists feeling more empathy toward the patient but they also identified more incidental findings (the files were chosen because of incidental findings in this randomized study) without taking more time to review the images.
Another study just recently presented (Ridley 2012) also demonstrated that including patient photographs in PACS systems likely leads to fewer misidentification errors. Researchers at Emory University developed a low-cost system for obtaining patient photographs at the time an imaging procedure was being done and integrating them via wireless connection with the images going to their PACS system. They then gave radiologists imaging studies to read that purposefully including some instances of misidentification. Those reading without patient photographs picked up only 12.5% of the misidentified patients. Those reading with the patient photographs detected 64% of the errors.
The American Association for Clinical Chemistry (AACC April 2009) reports some healthcare organizations are attaching patient photos to requisitions for Pap smears or other specimens that are being examined.
In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we briefly mentioned using photographs of patients when broadcasting an alert for a missing patient. We recommend that you include in your IT system a digital photograph of patients you identify as being at risk for wandering and elopement. Many communities, often in conjunction with their local chapter of the Alzheimer Association, have programs where families provide photos of their relatives with Alzheimer’s Disease or other dementia to the local police department to facilitate searches when such individuals go missing.
Patient photographs might also be used on patient identification cards issued by a healthcare system. This might help avoid “medical identify theft” or other fraudulent use of identification. Also, you’d be surprised at how issuing identity cards for your health system fosters loyalty to your system. We recall many years ago when our health system stopped issuing patient cards. The patients complained! They liked having them to carry around. It gave them a measure of security and sense of belonging. So don’t underestimate the potential value of such cards.
But are there downsides to using patient photographs? Though there is a paucity of literature on use of patient photographs for patient safety, we can certainly anticipate there might be unintended consequences. Just like many other examples we have seen, it could happen that photographs of two patients get mixed up. For example, one might anticipate two patients being admitted around the same time. Each would get photographed. It is conceivable that someone might print out both photographs and erroneously transpose them into the charts or IT system. That is one reason you should never do anything intended for more than one patient simultaneously.
And what about those patients (eg. trauma patients) whose faces may not be recognizeable on admission? And all those babies in the nursery look the same to me! And some patients, particularly those with long stays, may have considerable changes in appearance over time.
And how do you ensure that your staff actually use the photos to aid in patient identification? In a FMEA performed at one institution (Skibinski et al 2007) it was found that in those patients with a wristband present and checked, a second form of patient verification (photograph, verification of birthdate, positive response to stated name, etc.) was not checked 30% of the time. So not only is training and reinforcement necessary but some audit function would be appropriate.
We did find a real example of a downside to patient photographs in the literature. In our March 2010 What’s New in the Patient Safety World article “More on Radiation Safety” we reported on an outstanding article that appeared in the journal Radiotherapy & Oncology (Scorsetti et al 2010). Italian researchers performed a FMEA (failure mode and effects analysis) of their entire process of radiation therapy. During their focus on potential misidentification of patients they noted that a photo of each patient had been added to the medical record. However, these photos were often not representative of the patient’s appearance at the time of treatment so staff tended not to rely on the photographs.
Nevertheless, we think that using patient photographs makes a lot of sense in trying to avoid patient misidentification errors. One other common scenario where we think having patient photographs may be very important is the multiple applications/multiple windows scenario. Most health systems still do not have full integration of all their HIT systems. For example, you may be viewing the hospital electronic record for most patient data but may be viewing a radiologic image on the separate PACS system. Particularly if you have been looking through records on multiple patients it is easy to lose synchronization between the two applications so that you may be viewing the EHR on one patient and the PACS images of a different patient. We suspect that having patient photographs, rather than simply name and DOB, on every page in both systems would help avoid this mismatch.
The results of the Children’s Hospital of Colorado study and the Emory University study are very encouraging. We personally think that the addition of photographs to the EHR represent an important patient safety feature. Hopefully, concerns about HIPAA, privacy, and logistical issues can be overcome to apply the concept to multiple areas of patient safety.
AHRQ Health Care. Innovations Exchange. Innovation Profile: Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification.
Hyman D, Laire M, Redmond D, Kaplan DW. The Use of Patient Pictures and Verification Screens to Reduce Computerized Provider Order Entry Errors. Pediatrics 2012; 130: 1-9 Published online June 4, 2012 (10.1542/peds.2011-2984)
RSNA. RSNA Press Release. Patient Photos Spur Radiologist Empathy and Eye for Detail. December 2, 2008
Ridley EL. Integrating digital photos within PACS may cut ID errors. AuntMinnie.com June 20, 2012
AACC. Clinical Laboratory News. April 2009. Patient Safety Focus: Disconnection from Patients and Care Providers. A Latent Error in Pathology and Laboratory Medicine. An Interview with Stephen Raab, MD
Skibinski KA, White BA, Lin LI, et al. Effects of technological interventions on the safety of a medication-use system. Am. J. Health Syst. Pharm., Jan 2007; 64: 90 – 96
Scorsetti M, Signori C, Lattuada P, Urso G, Bignardi M, Navarria P, Castiglioni S, Mancosu P, Trucco P. Applying failure mode effects and criticality analysis in radiotherapy: Lessons learned and perspectives of enhancement.
Radiother Oncol. 2010 Jan 27. [Epub ahead of print]
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August 2, 2016
July 26, 2016
July 19, 2016
July 12, 2016
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
June 21, 2016
June 14, 2016
June 7, 2016
May 31, 2016
May 24, 2016
May 17, 2016
May 10, 2016
May 3, 2016
April 26, 2016
April 19, 2016
April 12, 2016
April 5, 2016
March 29, 2016
March 22, 2016
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
January 19, 2016
January 12, 2016
January 5, 2016
December 29, 2015
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
October 27, 2015
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
September 29, 2015
September 22, 2015
The Cost of Being Rude
September 15, 2015
September 8, 2015
September 1, 2015
August 25, 2015
August 18, 2015
August 11, 2015
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
July 14, 2015
July 7, 2015
June 30, 2015
June 23, 2015
June 16, 2015
June 9, 2015
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
May 5, 2015
April 28, 2015
April 21, 2015
April 14, 2015
April 7, 2015
March 31, 2015
March 24, 2015
March 17, 2015
March 10, 2015
March 3, 2015
February 24, 2015
February 17, 2015
February 10, 2015
February 3, 2015
January 27, 2015
January 20, 2015
January 13, 2015
January 6, 2015
December 30, 2014
December 23, 2014
December 16, 2014
December 9, 2014
December 2, 2014
November 25, 2014
November 18, 2014
November 11, 2014
November 4, 2014
October 28, 2014
October 21, 2014
October 14, 2014
October 7, 2014
September 30, 2014
More on Deprescribing
September 23, 2014
September 16, 2014
Focus on Home Care
September 9, 2014
September 2, 2014
August 26, 2014
August 19, 2014
August 12, 2014
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
July 22, 2014
July 15, 2014
July 8, 2014
July 1, 2014
Interruptions and Radiologists
June 24, 2014
June 17, 2014
June 10, 2014
June 3, 2014
May 27, 2014
May 20, 2014
May 13, 2014
May 6, 2014
April 29, 2014
April 22, 2014
April 15, 2014
Specimen Identification Mixups
April 8, 2014
April 1, 2014
March 25, 2014
March 18, 2014
March 11, 2014
March 4, 2014
February 25, 2014
February 18, 2014
February 11, 2014
February 4, 2014
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
January 7, 2014
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
December 3, 2013
November 26, 2013
November 19, 2013
November 12, 2013
November 5, 2013
October 29, 2013
October 22, 2013
October 15, 2013
October 8, 2013
October 1, 2013
September 24, 2013
September 17, 2013
September 10, 2013
September 3, 2013
August 27 2013
August 20 2013
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
June 11, 2013
June 4, 2013
May 28, 2013
May 21, 2013
May 14, 2013
May 7, 2013
April 30, 2013
April 23, 2013
April 16, 2013
April 9, 2013
April 2, 2013
March 26, 2013
March 19, 2013
March 12, 2013
March 5, 2013
February 26, 2013
February 19, 2013
February 12, 2013
February 5, 2013
January 29, 2013
January 22, 2013
January 15, 2013
January 8, 2013
January 1, 2013
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
December 11, 2012
December 4, 2012
November 27, 2012
November 20, 2012
November 13, 2012
November 6, 2012
October 30, 2012
October 23, 2012
October 16, 2012
October 9, 2012
October 2, 2012
September 25, 2012
September 18, 2012
September 11, 2012
September 4, 2012
August 28, 2012
August 21, 2012
August 14, 2012
August 7, 2012
July 31, 2012
July 24, 2012
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
June 26, 2012
June 19, 2012
June 12, 2012
June 5, 2012
May 29, 2012
May 22, 2012
May 15, 2012
May 8, 2012
May 1, 2012
April 24, 2012
April 17, 2012
April 10, 2012
April 3, 2012
March 27, 2012
March 20, 2012
March 13, 2012
March 6, 2012
February 28, 2012
February 21, 2012
February 14, 2012
February 7, 2012
January 31, 2012
January 24, 2012
January 17, 2012
January 10, 2012
January 3, 2012
December 20, 2011
December 13, 2011
December 6, 2011
November 29, 2011
November 22, 2011
November 15, 2011
November 8, 2011
November 1, 2011
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
September 27, 2011
September 20, 2011
September 13, 2011
September 6, 2011
August 30, 2011
August 23, 2011
August 16, 2011
August 9, 2011
August 2, 2011
July 26, 2011
July 19, 2011
July 12, 2011
July 5, 2011
June 28, 2011
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
May 24, 2011
May 17, 2011
May 10, 2011
May 3, 2011
April 26, 2011
April 19, 2011
April 12, 2011
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
March 15, 2011
March 8, 2011
March 1, 2011
February 22, 2011
February 15, 2011
February 8, 2011
February 1, 2011
January 25, 2011
January 18, 2011
January 11, 2011
January 4, 2011
December 28, 2010
December 21, 2010
December 14, 2010
December 6, 2010
November 30, 2010
November 23, 2010
November 16, 2010
November 9, 2010
November 2, 2010
October 26, 2010
October 19, 2010
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
September 7, 2010
August 31, 2010
August 24, 2010
August 17, 2010
August 10, 2010
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
July 20, 2010
July 13, 2010
July 6, 2010
June 29, 2010
June 22, 2010
June 15, 2010
June 8, 2010
June 1, 2010
May 25, 2010
May 18, 2010
May 11, 2010
May 4, 2010
April 27, 2010
April 20, 2010
April 13, 2010
April 6, 2010
March 30, 2010
March 23, 2010
March 16, 2010
March 9, 2010
March 2, 2010
February 23, 2010
February 16, 2010
February 9, 2010
February 2, 2010
January 26, 2010
January 19, 2010
January 12, 2010
January 5, 2010
December 29, 2009
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
November 24, 2009
November 17, 2009
November 10, 2009
November 3, 2009
October 27, 2009
October 20, 2009
October 13, 2009
October 6, 2009
September 29, 2009
September 22, 2009
September 15, 2009
September 8, 2009
September 1, 2009
August 25, 2009
August 18, 2009
August 11, 2009
August 4, 2009
July 28, 2009
July 21, 2009
July 14, 2009
July 7, 2009
June 30, 2009
June 23, 2009
June 16, 2009
June 9, 2009
June 2, 2009
May 26, 2009
May 19, 2009
May 12, 2009
May 5, 2009
April 28, 2009
April 21, 2009
April 14, 2009
April 7, 2009
March 31, 2009
March 24, 2009
March 17, 2009
March 10, 2009
March 3, 2009
February 24, 2009
February 17, 2009
February 10, 2009
February 3, 2009
January 27, 2009
January 20, 2009
January 13, 2009
January 6, 2009
December 30, 2008
December 23, 2008
December 16, 2008
December 9, 2008
December 2, 2008
November 25, 2008
November 18, 2008
November 11, 2008
November 4, 2008
October 28, 2008
October 21, 2008
October 14, 2008
October 7, 2008
September 30, 2008
September 23, 2008
September 16, 2008
September 9, 2008
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
August 5, 2008
July 29, 2008
July 22, 2008
July 15, 2008
July 8, 2008
July 1, 2008
June 24, 2008
June 17, 2008
June 10, 2008
June 3, 2008
May 6, 2008
April 29, 2008
April 22, 2008
April 15, 2008
April 8, 2008
April 1, 2008
March 25, 2008
March 18, 2008
March 11, 2008
March 4, 2008
February 26, 2008
February 19, 2008
February 12, 2008
February 5, 2008
January 29, 2008
January 22, 2008
January 15, 2008
January 8, 2008
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
December 4, 2007
November 20, 2007
November 13, 2007
November 6, 2007
October 30, 2007
October 23, 2007
October 16, 2007
October 9, 2007
October 2, 2007
September 25, 2007
September 18, 2007
September 11, 2007
September 4, 2007
August 28, 2007
August 21, 2007
August 14, 2007
August 7, 2007
July 31, 2007
July 24, 2007
July 17, 2007
July 10, 2007
July 3, 2007
June 26, 2007
June 19, 2007
June 12, 2007
June 5, 2007
May 29, 2007
May 22, 2007
May 15, 2007
May 8, 2007
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
April 2, 2007
March 26, 2007
March 19, 2007
March 12, 2007
March 5, 2007
February 26, 2007