Healthcare Consulting Services
January 4, 2011
Safer Use of PCA
Patient-controlled analgesia (PCA) has been a major development in pain management and, for the most part, has resulted in improved pain control and patient satisfaction, shorter lengths of stay, and better utilization of resources. Though having the theoretical built-in advantage that should prevent inadvertent narcotic overdose (i.e. as the patient becomes drowsy, he/she cannot press the button to infuse more narcotic), use of PCA pumps have been associated with multiple problems of their own. PCA is another example where new technologies effectively eliminate some problems but introduce new problems of their own. Our May 12, 2009 Patient Safety Tip of the Week Errors With PCA Pumps dealt with a number of errors that may occur during use of patient controlled analgesia (PCA) and our April 27, 2010 Patient Safety Tip of the Week Infusion Pump Safety dealt with infusion pump issues in general. And weve discussed the issue of postoperative respiratory depression due to opioids in our Patient Safety Tips of the Week for July 13, 2010 Postoperative Opioid-Induced Respiratory Depression and September 21, 2010 Dilaudid Dangers.
ECRI Institute in its Top 10 Health Technology Hazards for 2011 included oversedation during use of PCA infusion pumps as Number 7 on its list (see our January 2011 Whats New in the Patient Safety World column ECRIs Top 10 Health Technology Hazards for 2011).
In 2006, in response to growing concerns about respiratory depression in patients on PCA, the APSF (Anesthesia Patient Safety Foundation) convened a workshop to address related issues (Weinger 2006). And in 2009 and 2010 the APSF again called for greater scrutiny of PCA (patient-controlled analgesia) in the postoperative period (Weinger 2009, Overdyk 2010).
The ECRI paper notes that the true prevalence of respiratory depression in patients on PCA is much higher than previously suspected since better monitoring has been implemented and may be as high as 41%. The ECRI recommendations are for monitoring not just vital signs but also mental status, pulse oximetry and capnography. They also discuss how to correctly assess the patients, use double checks for both orders and pump programming, and consider alternatives to PCA.
Very timely is an excellent article on a safety initiative to reduce PCA errors (Paul 2010). They reviewed over 25,000 patients treated with PCA at several Hamilton Acute Pain Service sites (McMaster University) over a 7-year period. Approximately half the patients used PCA before a comprehensive safety intervention was initiated and half after. They were able to demonstrate a significant reduction in PCA errors after the intervention (odds ratio 0.28). And PCA pump programming errors virtually disappeared after the intervention was implemented.
Their intervention included several key elements. First, they purchased new PCA pumps. These pumps had both hard stops and soft stops. Importantly, the user-interface for programming the pumps allowed visualization of all key parameters on one screen (the old pumps had required staff to scroll through 5 screens). By the way, the comment about displaying all the key parameters on one screen is a great human factors design concept that should apply not only to pumps but also to your CPOE systems. Any time a provider needs to scroll or click through multiple screens the chance for errors increases.
Second, they developed pre-printed order forms, designed to match the programming parameters on the new PCA pumps and including choices of three opioid preparations and their concentrations. The authors also note that CPOE is further likely to enhance the safety of prescribing PCA since it can provide feedback to the prescriber, such as alerts about dose range limits, etc. Standardized dosing of opioids is often not possible, given the wide variation in patient sensitivity to the effects of opioids. Nevertheless, well-designed preprinted order forms or CPOE entry screens can provide the options necessary for clinicians to prescribe PCA in most cases.
Third, the instituted a policy requiring independent double checks by nursing of the PCA settings incorporated into the orders. Fourth, they required nurses review all PCA program settings during each shift and on shift handovers.
Fifth, they instituted a rigorous program of education and training for nurses. Any nurse who will be responsible for care of patients with PCAs must take a formal acute pain course with hands-on experience in pump programming. Lastly, they instituted a mandatory critical incident reporting program. And all these were in addition to the dedicated pain management service that they already had up and running for many years.
The article nicely summarizes the types and frequencies of the various sorts of errors associated with PCA. Overall (including both pre- and post-intervention cases), pump programming errors accounted for 33.9% of the PCA errors. 14.6% were caused by orders by non-pain-service providers, 12.9% by inadequate nurse education, 7.8% by PCA by proxy, and 1.6% by pump hardware failure. Over 77% of errors resulted in incorrect doses, most often an overdosing but occasionally underdosing. Most errors did not result in patient harm and none resulted in death. However, 34% of patients did have some harm, most often respiratory depression requiring oxygen or rescue with a narcotic antagonist (see also our Patient Safety Tip of the Week for July 13, 2010 Postoperative Opioid-Induced Respiratory Depression for a discussion of the phenomenon of renarcotization).
The summary of a 2006 workshop on postoperative respiratory depression sponsored by APSF (Weinger 2006) is well worth reading. Most participants felt that the same monitoring should be applied to all patients, noting that even low-risk patients occasionally develop respiratory failure while receiving opioids by PCA or neuraxial techniques. They also note that avoiding even one case of patient harm from respiratory depression could justify the cost of monitoring all patients. Thus a policy of zero tolerance for harm due to postoperative opioid-induced respiratory depression should be the goal. They all noted inadequacies of current monitoring systems but recommend at least pulse oximetry and continuous respiratory monitoring on all patients on PCA. They stressed that oxygen should not be used unless there is a specific indication since oxygen therapy may significantly delay recognition of respiratory depression.
Frank Overdyk (Overdyk 2010), a key participant in the 2006 APSF conference and long an advocate and researcher on respiratory depression from postoperative PCA, decries the fact that 3 years after the original APSF call for action very few hospitals have instituted continuous monitoring in PCA patients. He notes cases he has reviewed where monitoring intervals as far apart as every 4 hours have contributed to patient harm. He also stresses the false confidences that both nurses and physicians have in PCA. Nurses often think the lockout mechanism is foolproof. And physicians often think that respiratory depression only occurs in opioid-nave patients, clearly a fallacy since it occurs in anyone on PCA.
We wont reiterate here our prior discussion on pump programming errors or PCA by proxy. See our May 12, 2009 Patient Safety Tip of the Week Errors With PCA Pumps for those discussions and references to a whole host of great resources from ISMP (Institute for Safe Medication Practices).
So here is what your organization should be doing:
PCA is a great therapeutic intervention that has lots of positives but it also has its downsides and risks that your must try to minimize. APSF has an upcoming Conference on Monitoring Postoperative Drug-Induced Respiratory Depression this June so expect to hear a lot more about progress in this area soon.
ECRI. ECRI Institutes 2011 Top 10 Health Technology Hazards. Health Devices 2010; 39(11): 386-398
Weinger MB. Dangers of Postoperative Opioids. APSF Workshop and White Paper Address Prevention of Postoperative Respiratory Complications. APSF Newsletter 2006; 21: 61-67 Winter 2006-2007
Weinger MB, Stoelting RK. Special Editorial. Dangers of Postoperative OpioidsIs There A Cure? APSF Newsletter 2009; 24(2): 25-26 Summer 2009
Overdyk FJ. Postoperative Opioids Need System-Wide Overhaul (Letter to the Editor). APSF Newsletter 2010; 24(4): 61, Winter 2009-2010
Paul JE, Bertram B, Antoni K, et al. Impact of a Comprehensive Safety Initiative on Patient-controlled Analgesia Errors. Anesthesiology. 113(6): 1427-1432, December 2010
Cohen MR, Weber RJ, Moss J (Institute for Safe Medication Practices). Patient-Controlled Analgesia: Making it Safer for Patients. A continuing education program for pharmacists and nurses. ISMP. April 2006 http://www.ismp.org/profdevelopment/PCAMonograph.pdf
Conference on Monitoring Postoperative Drug-Induced Respiratory Depression (June 08, 2011, Phoenix, AZ).
Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period
Print Safer Use of PCA
January 11, 2011
NPSA (UK) How to Guide:
Five Steps to Safer Surgery
The UK National Health Services NPSA (National Patient Safety Agency) recently released its How to Guide Five Steps to Safer Surgery. It draws heavily on work done in the US on team training and techniques for improving communication in the perioperative period.
The five steps are:
While you will all recognize steps 2-4 as those involved in the WHO Surgical Safety Checklist (see our Patient Safety Tips of the Week for July 1, 2008 WHOs New Surgical Safety Checklist and January 20, 2009 The WHO Surgical Safety Checklist Delivers the Outcomes and September 23, 2008 Checklists and Wrong Site Surgery), the real focus of the new NPSA guide is on the briefings and debriefings.
Preoperative briefings (sometimes called huddles) and postoperative debriefings are tools we have strongly recommended since we first began talking about the TeamSTEPPS training program back in 2007 (see our 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).
Many of our columns have discussed teamwork, crew/cockpit resource management (CRM), communication, and handoffs. One of the problems we encounter in planning and implementing such team training programs, however, is measuring success of such programs. Many of the benefits of such teamwork training help the team function much better in emergency circumstances or in preventing unwanted events that are very rare to start with (eg. wrong site surgeries). But such events are likely to be absent in both pre- and post-intervention studies. Metrics of operating room efficiency can be used. But most assessments need to rely on process measures that are fairly labor-intensive to collect. We previously noted a study by Lingard et al (Lingard 2008) that used a checklist to structure short team briefings and documented reduction in the number of communication failures. A study by Havlerson et al. from Northwestern Memorial Hospital (Halverson et al 2009) attempts to demonstrate the benefits of an intensive crew resource management training for all surgeons, anesthesiologists, OR nursing and ancillary personnel. The curriculum included a 4-hour training class plus some in-OR coaching. The intervention resulted in performance of a preoperative briefing in 86% of cases 2 weeks after the intervention but this fell to 66% at 6 months post-intervention. There was a modest improvement in formal announcement of intraoperative changes in staffing. There was no significant difference in timing of prophylactic antibiotic administration or case turnover times. A modest improvement in on-time first case starts may have been influenced by a concomitant intervention. A survey showed that 75% of participants had the perception that the briefings provided a better sense of teamwork. However, they noted a marked disparity in those perceptions by discipline, with nurses and anesthesiologists perceiving more benefit from the briefings than surgeons did.
But most such studies were measuring impact on perceptions and some soft outcomes. We needed confirmation that such team training programs and exercises actually led to improved patient outcomes. That evidence came late in 2010 when results of a visionary program at the Veterans Administration system were published (Neily 2010). Based upon a pilot project experience, the VA in 2006 began implementation of a Medical Team Training (MTT) program at all its hospitals nationwide. Using crew resource management (CRM) principles, clinicians were trained to work together as teams, challenge each other, use checklist-guided preoperative briefings and postoperative debriefings, and use other communication strategies. (For a thorough description of the VA MTT program see Dunn 2007). After a 2-month period of planning and preparation, each team attended a full-day session that included lecture and group interactive sessions, and videos. Over the next year, 4 structured followup telephone interviews were conducted to support, coach and assess the MTT implementation. The investigators were able to compare improvement in surgical mortality between those centers that had implemented MTT and those that had not yet done so. Using techniques to risk adjust and minimize bias, they concluded that the reduction in surgical mortality rate was 50% greater in those centers that had implemented MTT. Moreover, the found a dose-response relationship in which for every quarter of the program a reduction of 0.5 deaths per 1000 procedures occurred. They also looked at the impact of briefings and debriefings and found that for every increase in the degree of compliance with briefings and debriefings there was a reduction in the surgical mortality rate of 0.6 per 1000 procedures. The authors attributed much of the success of the program to the preoperative briefings. In addition to the statistical improvement in mortality they note they shared many stories of successes related to information revealed during the preoperative briefings. They also found that information from the postoperative debriefings was very useful in resolving issues such as fixing broken equipment, having appropriate backup instruments available, improving communication with radiology, etc. The same group (Paull 2010) also demonstrated that implementation of preoperative checklist-driven briefings was associated with increased compliance with antibiotic prophylaxis and DVT prophylaxis.
Another study evaluating the impact of an MTT program for the OR (Wolf 2010) showed significant reduction of case delays and sustained improvement in frequency of preoperative delays, handoff issues, equipment issues/delays, and adherence to antibiotic prophylaxis protocols.
The NPSA Five Steps to Safety Surgery also recommends use of IHIs Surgical Trigger Tool or modifications to identify perioperative adverse events that can be measured and incorporated into your overall perioperative quality program.
Also 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.
There are some key points in implementing such team training programs. One study on the VA MTT implementation (Paull 2009) noted that involvement of facility leadership (Director, Chief of Staff, Nurse Executive, Chief of Surgery, Chief of Anesthesiology, and OR Nurse Manager) was the factor most predictive of successful implementation of briefings/debriefings. The Dunn paper (Dunn 2007) stresses the importance of a clinical connection between the faculty and the other participants. Also, though the principles of CRM are rooted in aviation the program emphasizes that examples should all come from healthcare, not aviation. That paper has useful recommendations about scheduling the educational sessions, particularly ensuring a sufficient number of attendees to ensure adequate interactive discussion.
In all of these implementations, the preoperative briefings and the postoperative debriefings have been the most important component. In most cases they have been checklist-guided. Examples of such checklists for the preoperative briefings may be found on either the NHS Patient Safety First website or the VA website. Video examples of preoperative briefings may also be found at the NHS website or the VA website.
Examples of such checklists for the postoperative debriefings may be found on either the NHS Patient Safety First website or the VA website. Basically, in the debriefings you are asking What went well?, What didnt go well? and What could we do better next time?. As above, youll often identify the need to fix broken equipment or ensure the availability of appropriate backup instruments. Sometimes its something simple like tray set-ups or equipment set-ups that interfered with the surgeons movements during the procedure.
There is a science to developing checklists. In our September 23, 2008 Patient Safety Tip of the Week Checklists and Wrong Site Surgery we referenced an excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists. And our July 6, 2010 Patient Safety Tip of the Week Book Reviews: Pronovost and Gawande provided tips on checklist design and use from some of the works of Peter Pronovost and Atul Gawande.
Checklists that are too complicated are not good. We do have a tendency to add too many things to the checklists. Generally you should keep checklists to fewer than 10 items. Checklists should also be reviewed and revised as needed. Items that are not providing useful information can be deleted. Our December 9, 2008 Patient Safety Tip of the Week Huddles in Healthcare discussed an article by Nundy and colleagues at Johns Hopkins (Nundy 2008). They used a very simple format for pre-operative briefings that led to a 31% reduction in unexpected delays in the OR and a 19% reduction in communication breakdowns that lead to delays. The tool they used was simple and consisted of 5 key items:
But one of the unsaid messages in the Nundy paper is the KISS (Keep It Simple, Stupid) principle. Anticipate things and try to discuss the most serious things that might happen, but dont make the process so complex and long that team members lose their attention. A typical pre-op huddle or briefing ordinarily takes no more than 3-4 minutes.
Some of the issues that might be discussed in a pre-op briefing/huddle are:
We have long advocated that the surgical fire risk be discussed as part of the pre-op huddle (or pre-op briefing) and, if the case is considered high-risk, respective roles of all OR participants are called out during the surgical timeout. Our January 2011 Whats New in the Patient Safety World column noted an effort to promote fire safety in the OR (Murphy 2010) in which the San Francisco VA developed a checklist The Surgical Fire Assessment Protocol. This checklist/protocol is actually printed on the reverse side of their larger preoperative briefing checklist. This is really a very good tool! The fire risk is assessed by a simple numerical scale. If the score is 3 (high risk) the rest of the form is filled out, which basically delineates the respective roles of all those participants. Thats a really good way to remind all about their responsibilities if a fire occurred. Its also an example of how you can use cascading checklists to avoid putting too many items on a single checklist.
Most importantly, the mere performance of the briefings and debriefings fosters a sense of belonging to teams, empowerment for all members, and better communication. These lead not only to a culture of safety but they also significantly improve job satisfaction for all involved.
It is very apparent now that MTT programs and use of preoperative briefings (huddles) and postoperative debriefings are extremely useful tools that improve not only teamwork and communication but also result in improved efficiencies and improved patient outcomes. Those of you that have not yet implemented such programs should be strongly considering these valuable additions to your patient safety programs.
By the way, these are not just for the OR! Our December 9, 2008 Patient Safety Tip of the Week Huddles in Healthcare also discussed how huddles and briefings can be useful in a variety of healthcare situations, not just the preoperative one.
NPSA (UK). How to guide to the five steps to safer surgery. December 10, 2010
NHS Patient Safety First. video demonstrating sample pre-op briefings
NHS Patient Safety First. Quick guide to briefing and debriefing.
Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
Halverson AL, Andersson JL, Anderson K, et al. Surgical Team Training. The Northwestern Memorial Hospital Experience. Arch Surg2009; 144(2):107-112
Neily J, Mills PD, Young-Xu Y, et al. Association Between Implementation of a Medical Team Training Program and Surgical Mortality. JAMA. 2010; 304(15): 1693-1700
Dunn EJ, Mills PD, Neily J, et al. Medical Team Training: Applying Crew Resource Management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007; 33: 317-325
Paull DE, Mazzia LM, Wood SD, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg 2010; 200(5): 620-623
Wolf FA, Way LW, Stewart L. The Efficacy of Medical Team Training: Improved Team Performance and Decreased Operating Room Delays: A Detailed Analysis of 4863 Cases. Annals of Surgery 2010. 252(3): 477-485
IHI. Surgical Trigger Tool for Measuring Peri-operative Adverse Events (IHI Tool)
IHI. Surgical Trigger Tool Kit. August 2006
Sax HC, Browne P, Mayewski RJ, et al. Can Aviation-Based Team Training Elicit Sustainable Behavioral Change? Arch Surg.2009; 144(12):1133-1137
Paull DE, Mazzia LM, Izu BS, et al. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Am J Surg 2009; 198(5): 675-678
VETERANS HEALTH ADMINISTRATION Preoperative Briefing Guide for Use in the Operating Room
VETERANS HEALTH ADMINISTRATION Postoperative Briefing Guide for Use in the Operating Room
VETERANS HEALTH ADMINISTRATION Preoperative Briefing Video.
Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use
of Emergency and Abnormal Checklists. January 2006.
Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, Andrew Knight A, Rowen LC, Duncan M, Syin D, Makary MA. Impact of Preoperative Briefings on Operating Room Delays: A Preliminary Report. Arch Surg 2008; 143(11):1068-1072
Murphy J. A New Effort to Promote Fire Safety in the OR.
Topics In Patient Safety (TIPS) 2010; 10(6): 3
SF VAMC Surgical Fire Risk Assessment Protocol
January 18, 2011
More on Medication Errors in
So you work in an acute care hospital, not a long-term care (LTC) facility dont stop reading!!! Youll see that you may be responsible for many of the medication errors that occur at LTC facilities.
We did a pretty thorough review on this topic in our July 21, 2009 Patient Safety Tip of the Week Medication Errors in Long-Term Care but are always happy to do updates when new information becomes available.
ISMP Canada recently reported on a 9-year experience with incidents in long-term care settings in their medication incident reporting database (ISMP Canada 2010). That database contained almost 5000 incidents in long-term care (probably a considerable underreporting) and they found harm or death occurred in 2.8%. When they analyzed the cases with harm or death, 3 main themes arose:
The big three high-alert medications involved in incidents in LTC were anticoagulants, insulin, and opioids. Most of the anticoagulant incidents involved errors in monitoring patients on warfarin therapy. The insulin errors were similar to those that we see in acute care (see our November 2, 2010 Patient Safety Tip of the Week Insulin: Truly a High-Risk Medication). The opioid incidents were interesting in that one of the top four opioid incident themes related to Fentanyl patches. The latter included cases where the wrong dose Fentanyl patch was applied and cases where old Fentanyl patches were not removed when new ones were applied, resulting in multiple Fentanyl patches releasing drug into the patients system. Note that ISMP Canada had previously done a safety bulletin on incidents involving Fentanyl patches in multiple settings (ISMP Canada 2009).
The incidents related to anxiolytic-sedative medications or antipsychotic medications most often resulted in falls. The falls typically occur in patients who get drowsy or confused on these medications, though some may also cause orthostatic hypotension as a potential cause for falls.
And, of course, LTC patients are particularly prone to errors in transitions of care since (a) they are generally admitted from an acute care facility and (b) they often require transfers to and from acute care hospitals. But there are also several other factors that predispose LTC patients to medication errors during such transitions of care. One is that when a patient is transferred from an acute care hospital to a LTC facility, the orders are often either (a) faxed or (b) photocopied (c) carbon-copied or (d) verbal, all being error-prone methods.
We previously have discussed how decimal points may be obscured in orders that are fax copies or carbon copies or photocopies (see our March 12, 2007 Patient Safety Tip of the Week 10x Overdoses). We also previously noted a case where medication lists from an SNF on two separate patients were faxed to an acute hospital at the same time. As a result, one patient was actually begun on all his own medications plus those intended for the second patient. Several days went by before the error was recognized. A recent ISMP Medication Safety Alert (ISMP 2010) pointed out the opposite problem: multiple pages may be pulled through the scanner or fax machine at the same time (causing a whole sheet to be missed), resulting in omission of multiple drugs for a patient. You need to have strict policies and procedures that require all received fax materials clearly state the patients name and other identifiers on each page and that each batch of faxed materials have a cover sheet which tells you how many pages to expect. If the expected number of pages is not received do not accept the fax. Contact the party doing the faxing and ask them to resend.
In our July 21, 2009 Patient Safety Tip of the Week Medication Errors in Long-Term Care we cited a study (Tjia et al 2009) looking at medication discrepancies in patients transitioning from acute hospitals to long-term care facilities that found at least one medication discrepancy occurred in 71.4% of admissions to the SNF and in 21.3% of all medications. Also the discharge summary and the patient care referral form did not match in 52.3% of cases. Moreover, there is often a delay in medication administration for those SNF patients transferred from acute care facilities, especially those transferred in the evening.
But another factor that wed think would protect against errors may also actually contribute to errors in some cases: familiarity with the patient. The ISMP Canada Safety Bulletin provides an example where a nurse in an LTC facility, upon transfer of a patient back from an acute care hospital, miscopied a medication dosage from faxed materials. When staff called the physician for orders, the physician (who had known the patient previously and had followed the resident in the acute hospital) simply instructed the staff to continue the same orders.
Some LTC facilities do not have their own pharmacies so rely on outside sources for their medication supplies. Often they have multiple different sources and their access to some medications may not be immediate (Stefanacci 2008).
It is often difficult to get a handle on the frequency of medication errors in LTC because the data sources are often not reporting the same metrics. SNFs commonly report on errors during the medication administration phase. Therefore, things like wrong dose, dose omission, wrong time, wrong patient, etc. tend to show up frequently in statistics. The IOM report Preventing Medication Errors notes the rate of medication administration errors in SNFs to range from 6 to 20 per 100 opportunities/doses. Wrong-time errors are particularly common in LTC facilities. Stefanacci (Stefanacci 2008) notes that a typical med pass in a LTC facility lasts over 2 hours so that it may be almost impossible for a nurse to administer all medications within 1 hour of scheduled time.
But some more prospective studies have demonstrated that errors in the ordering and monitoring stages are equally important, and those are often not reported in the LTC incident databases. Errors in the monitoring stage are particularly common causes of preventable adverse drug events in LTC facilities (Gurwitz 2005).
The IOM report also discusses underutilization of medications in the LTC population. They cite failure to use ACE inhibitors in CHF patients, aspirin and beta blockers in post-MI patients, antiplatelet agents in post-stroke patients, calcium supplements in patients with osteoporosis and others as common in LTC populations. There are some drugs, most notably warfarin in patients with atrial fibrillation, that are often not prescribed in the elderly because they are too risky despite evidence that the risk:benefit ratio may actually be better in some elderly patients.
Overutilization also occurs. Youve heard us on multiple occasions discuss the problem of patients being started on a proton-pump inhibitor or H2-blocker prophylactically while acutely ill in an ICU but never having those drugs discontinued, including after discharge. We actually recommend that every LTC facility, on receiving a patient from an acute care facility, specifically question the appropriateness of either of those drug categories.
Many of the technological interventions to reduce medication errors and adverse drug events, such as computerized physician order entry (CPOE), bedside medication verification (barcoding), and clinical decision support tools have not yet been widely implemented in LTC settings. Even where they have been implemented, dangerous workarounds have occurred more frequently in LTC/SNF settings than in acute care settings (Patterson 2006). But the good news is that some IT solutions have been successful in the LTC setting. Computerized alerts for renal dosing in a LTC setting (Field et al 2009) were successful for reducing the maximum frequency of medications, avoiding medications that should be avoided, and supplying missing information (such as a current creatinine level).
Weve done several columns regarding use of Beers List, Medication Therapy Management (MTM) programs, the Good Palliative-Geriatric Practice (GP-GP) algorithm, etc. in helping manage medications in the elderly. Most of those can be accessed via our October 19, 2010 Patient Safety Tip of the Week Optimizing Medications in the Elderly. While these are often applied to community-based populations, there is no reason they should not be being applied to the elderly in LTC settings as well.
Fortunately, there are some great tools out there to help you develop your medication safety programs in the LTC setting. The Massachusetts Coalition for the Prevention of Medical Errors developed a 200-page workbook for reduction of medication errors in long-term care. This is a comprehensive resource that takes you all the way from developing a culture of safety, educating staff, through setting up policies and procedures for medication management, and implementing quality improvement programs to monitor progress and improve. ISMP Canadas Medication Safety Self-Assessment (MSSA) program administers the assessment across all levels of the healthcare continuum. The tool is administered via secure internet access and for LTC facilities consists of 125 items by which LTC facilities assess their relative performance in medication safety. Though still in its infancy, the program has identified both strengths and weaknesses in medication safety systems in LTC facilities. On the positive side, LTC facilities tend to use computerized pharmacy information systems with resident medication profiles, have allergies listed on each page of the MAR, dispense by unit dose, use patient photographs to assist in correct patient identification, have standardized administration times, and have pharmacists available to work with care teams. But areas they have identified as being in need of improvement are: dealing with high-alert medications, minimizing interruptions during the medication administration processes, lack of CPOE/clinical decision support systems, use of dangerous abbreviations, and relative lack of use of patient safety learning tools.
So what should you be doing to reduce the occurrence of medication errors in LTC?
The bottom line is that we have a whole lot of opportunities to improve medication safety in the LTC/SNF setting and especially to improve our coordination of care between the LTC/SNF and acute care settings. As CMS and other payors switch to new reimbursement methodologies intended to reduce unnecessary admissions and readmissions to acute care hospitals, it becomes increasingly important for acute care facilities to work closely with LTC facilities to minimize the medication errors that often lead to avoidable hospitalizations.
ISMP Canada. Medication Incidents Occurring in Long-Term Care. ISMP Canada Safety Bulletin 2010; 10(9): 1-3 December 10, 2010
ISMP Canada. Analysis of International Findings from Incidents Involving Fentanyl Transdermal Patches. ISMP Canada Safety Bulletin 2009; 10: 1-2 (December 30, 2009)
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
Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med. 2009; 24:630-635
Stefanacci RG (Spivack BS Series Editor). Preventing Medication Errors. Annals of Long Term Care 2008; 9/5/2008
IOM (Institute of Medicine). Institute of Medicine Report: Preventing Medication Errors. July 2006.
IOM (Institute of Medicine). Incidence Of Medication Errors In Nursing Homes. In Institute of Medicine Report: Preventing Medication Errors. July 2006.
Gurwitz JH. Field TS. Rochon JJ et al. The incidence of adverse drug events in two large academic long-term care facilities. American Journal of Medicine 2005; 118(3):251-8
Patterson ES. Rogers ML. Chapman RJ. Render ML. Compliance with intended use of Bar Code Medication Administration in acute and long-term care: an observational study.
Human Factors 2006;. 48(1):15-22
Field TS, Rochon P, Lee M, et al. Computerized Clinical Decision Support During Medication Ordering for Long-term Care Residents with Renal Insufficiency.
JAMIA 2009; 16: 480-485
Massachusetts Coalition for the Prevention of Medical Errors. http://www.mass.gov/?pageID=eohhs2terminal&L=4&L0=Home&L1=Consumer&L2=Community+Health+and+Safety&L3=Patient+Safety&sid=Eeohhs2&b=terminalcontent&f=dph_patient_safety_c_ltc_error_reduction&csid=Eeohhs2
MASSPRO, The Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Federation, Betsy Lehman Center for
Patient Safety and Medical Error Reduction and the Massachusetts Department of Public Health. A Systems Approach to Quality Improvement in Long-Term Care:
Safe Medication Practices Workbook. 2005
ISMP Canada. Medication Safety Self-Assessment for Long-Term Care.
January 25, 2011
On several occasions we have talked about the patient safety issues related to sedation for medical procedures in children (see our May 25, 2010 Patient Safety Tip of the Week Propofol Issues). The incidence of complications of pediatric procedural sedation varies by type of procedure, type of sedating agent, etc. One study (Larsen 2009) looked at the safety of propofol administration by pediatric intensivists for pediatric outpatient procedures in a single institution over a 6-year period. In over 4700 cases, major complications occurred in only 0.1% of cases, though minor complications were noted in 15% of cases. Another (Mallory et al 2010), using data from the Pediatric Sedation Research Consortium on over 25,000 pediatric patients (majority performed in radiology) documented airway and respiratory adverse events in 3.9% of cases of cases. Cases included two aspirations and one cardiac arrest but there were no deaths but in 2.4% of cases interventions beyond simple airway repositioning were required. Complications were more common in children less than 2 months, ASA class greater than 2, use of adjunctive opioids or midazolam, or adjunctive use of anticholinergics. In an ER setting (Pena 1999) pediatric procedural sedation was associated with a 2.3% incidence of adverse events, though none required hospitalization, intubation or pharmacological reversal.
Last month some terrific resources on procedural sedation for children became available. Though they are intended for those involved with care of children, most of the recommendations apply equally to adults.
NICE (UKs National Institute for Health and Clinical Excellence) published a guideline on sedation for diagnostic and therapeutic procedures in children and young people (NICE 2010). And then a whole issue of Clinical Pediatric Emergency Medicine was devoted to the issue of procedural sedation in children.
The full NICE guideline contains 385 pages plus appendices but also has a useful quick reference guide and informational materials for patients and families. The full guideline has a comprehensive review of the literature and evidence base. It emphasizes that prodedural sedation is administered and monitored by a team and notes the training and skill needs of various team members for each level of sedation. It has particularly good sections on pre-procedure assessment and preparation (including the role of the parents). It also has good discussion on alternatives and adjuncts that may be used along with sedation. It breaks down recommendations for specific procedures (eg. painful ones, imaging, dental, endoscopy, etc.) and has some good algorithms and an excellent discussion of individual pharmacological agents used.
The Clinical Pediatric Emergency Medicine theme issue also has a nice article on the pharmacology of the agents commonly used in pediatric procedural sedation (Kost 2010) and one on choosing a regimen that fits the situation (Bennett 2010) with multiple case examples. For example, the regimen you might choose for sedation in a CT scan that does not hurt but could take as long as 45 minutes might be considerably different than one youd use for reduction of an orthopedic injury that might be painful but brief. However, the article by Nagler and Krauss (Nagler 2010) on monitoring is probably the most useful. They discuss the historical evolution of guidelines for monitoring procedural sedation and provide comment on the current guidelines from the American Society of Anesthesiologists, the American Academy of Pediatrics, and the American College of Emergency Physicians. While the monitoring should be tailored to the specific pharmacologic agent being used for sedation, almost all those agents have respiratory risks necessitating close monitoring of parameters related to respiration, by both observational and mechanically recorded means. Some drugs, particularly propofol, may also have cardiovascular risks necessitating closer observation of cardiovascular parameters as well.
Nagler and Krauss note that central respiratory depression due to the sedating agents is not the only cause of respiratory complications. Obstructive apnea and laryngospasm may also occur with some agents and aspiration is always a risk. They have a nice discussion of how the capnographic waveform and respiratory rate monitoring may be helpful in quickly determining the cause of the respiratory problem and leading to the most appropriate intervention. They point out that direct clinical observation has traditionally been the cornerstone of monitoring during procedural sedation, observing respiratory rate and depth and skin color. But they note that continuous observation is almost impossible and therefore mechanical means of monitoring are critical. (Youve also heard us say, on numerous occasions, that we are poor at predicting which patients have respiratory depression by just watching the patient. We have had medical students, residents, and attendings all observe patients on whom we had arterial blood gases and they did little better than chance at picking out which patients had respiratory depression.). They discuss the usefulness, as well as the limitations, of transthoracic impedance plethysmography, continuous pulse oximetry, capnorgaphy, EKG monitoring and noninvasive blood pressure monitoring and have a good discussion of future directions in monitoring procedural sedation. They also acknowledge the challenges that may occur in applying some of the monitoring tools in children who are uncooperative.
While providers often tailor their monitoring protocols to the intended level of sedation, in reality it is often impossible to predict the level of sedation that will be reached. Therefore, your monitoring must anticipate that the patient may well end up at a level of sedation deeper than had been planned.
The issue of use of oxygen during procedures is a complicated one. In several of our previous articles we have noted that oxygen treatment may actually cause a delay in recognition of respiratory depression. Nagler and Krauss acknowledge that risk but also note that pediatric patients are more vulnerable to precipitous onset of oxygen desaturation because they have a smaller residual capacity relative to total lung volume. Therefore, they recommend use of oxygen before and during procedures in children but recommend use of direct observation and capnography to watch for respiratory depression. Capnography becomes extremely important under such circumstances. A study (Deitch et al 2010) on procedural sedation in adults showed significantly fewer patients with hypoxia in the group monitored by capnography. The 17% absolute risk reduction translated to a number needed to treat (NNT) of 6 cases to prevent one episode of hypoxia. Capnography recognized 100% of the patients who developed hypoxia and did so a median time of 60 seconds before hypoxia developed. That delay meant the physicians usually had adequate time to intervene. We know of no comparable controlled trial in a pediatric population.
Monitoring does not end when the procedure is completed. Nagler and Krauss note that, although the vast majority of adverse events occur within 25 minutes of the last sedataion dose, nearly 10% occur after the procedure has ended. They therefore recommend the duration of monitoring be based on clinical and physiological parameters rather than the clock.
Assessment of readiness for discharge is critical in both adults and pediatrics. Nagler and Krauss note use of validated tools like the Vancouver Sedative Recovery Scale (McNab 1991) or the University of Michigan Sedation Scale (Malviya 2002) in determining readiness of discharge after procedural sedation. The NICE guideline recommends use of checklists to ensure that the child has returned to presedation state but also emphasizes that factors like caregiver readiness and travel distance should be considered.
The Mayo Clinic did a FMEA (Brice 2010) after a routine audit had disclosed several patients had not had their discharge assessment completed before they were discharged after MRIs which required sedation. That problem apparently began after they had switched from a printed discharge form to an electronic form (yet another unintended consequence of technology!). During their FMEA they recognized that the printed form had served as a visual cue to nursing staff that the patient had been sedated and they needed to perform a formal assessment. One of the interventions they implemented was use of color-coded stickers and corresponding color-coded wristbands for patients to denote they had received sedation for MRI. Note that the issue of color-coded wristbands and bracelets has important implications (see our September 18, 2007 Patient Safety Tip of the Week Wristbands: The Color-Coded Conundrum and our October 2008 Whats New in the Patient Safety World More on Color-Coded Wristbands). In fact, the Mayo group initially chose hot pink wristbands but had to switch to a teal color when the Minnesota hospital group adopted a standardized set of colors for wristbands.
Note that adults and older children who may have drivers licenses should always be accompanied by an adult who can drive them home after discharge. They should not be allowed to drive themselves. Many sites cancel and reschedule procedures when such patients show up for a procedure requiring sedation without being accompanied by such a driver.
In addition to the potential patient risks inherent in procedural sedation, you need to consider the potential financial and time costs involved and plan your case selection and workflows well. In our August 2010 Whats New in the Patient Safety World column Sedation Costs for Pediatric MRI we noted a Canadian study (Vanderby 2010) that addressed the financial impact of sedation for MRI scanning in pediatrics. They found that the average time spent in the MRI suite was 2 hours and 21 minutes for children scanned awake, 3 hours 38 minutes for those sedated, and 4 hours 7 minutes for those anesthetized. Corresponding average costs (in Canadian dollars) were $54.68, $177.27, and $522.73 respectively. This article has a good discsussion about workflow and personnel issues and has some good lessons learned that you may apply in your organization. Good reason to consider the appropriateness of the MRI scan in the first place!
Larsen R,Galloway D, Wadera S, et al. Safety of Propofol Sedation for Pediatric Outpatient Procedures. Clin Pediatr (Phila) 2009; 48: 819-823
Mallory MD, Baxter AL, Yanosky DJ, Cravero. JP. Use of Propofol for Sedation of Pediatric Patients by Emergency Physicians: A Report from the Pediatric Sedation Research Consortium (abstract). Pediatric Academic Societies meeting May 1, 2010
Pena BM, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 1999; 34: 483-91
NICE clinical guideline 112. Sedation in children and young people. Sedation for diagnostic and therapeutic procedures in children and young people. December 2010
NICE page with access to all materials
quick reference guide
Procedural Sedation in Children (theme issue). Clinical Pediatric Emergency Medicine 2010; 11(4): 231-306
Kost S, Roy A. Procedural Sedation and Analgesia in the Pediatric Emergency Department: A Review of Sedative Pharmacology. Clinical Pediatric Emergency Medicine 2010; 11(4): 233-243
Bennett J, DePiero A, Kost S. Tailoring Pediatric Procedural Sedation and Analgesia in the Emergency Department: Choosing a Regimen to Fit the Situation. Clinical Pediatric Emergency Medicine 2010; 11(4): 274-281
Nagler J, Krauss B. Monitoring the Procedural Sedation Patient: Optimal Constructs for Patient Safety. Clinical Pediatric Emergency Medicine 2010; 11(4): 251-264
Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta P. Does End Tidal CO2 Monitoring During Emergency Department Procedural Sedation and Analgesia With Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled Trial. Annals of Emergency Medicine 2010; 55(3): 258-264
AJ Macnab AJ, Levine M, Glick N. et al. A research tool for measurement of recovery from sedation: The Vancouver Sedative Recovery Scale. Journal of Pediatric Surgery 1991; 26: 1263-1267
Malviya S, Voepel-Lewis T, Tait AR, et al. Depth of sedation in children undergoing computed tomography: validity and reliability of the University of Michigan Sedation Scale (UMSS). British Journal of Anaesthesia 2002; 88(2): 241-245
Brice J. Colored wristbands solve MR safety problem at Mayo Clinic. AuntMinnie.com January 17, 2011
Vanderby SA, Babyn PS, Carter MW, et al. Effect of Anesthesia and Sedation on Pediatric MR Imaging Patient Flow. Radiology 2010; 256(1): 229-237
February 1, 2011
MRI Safety Audit
Weve raised safety issues related to MRI scanning in multiple previous articles. In our Patient Safety Tips of the Week February 19, 2008 MRI Safety we discussed Joint Commissions Sentinel Event Alert Preventing accidents and injuries in the MRI suite and the American College of Radiology's updated guidance document for safe MR practices (Kanal et al 2007). We wont repeat here the numerous recommendations in those articles. But we did emphasize that your quality improvement program needs not only to review all incidents and near misses related to MR imaging but that you should also perform some sort of audits of adherence to the screening and other safety procedures. Results need to be incorporated into feedback to staff and lessons learned need to be readily shared. We also suggested that safety in the MRI suite is a great topic for a topic for FMEA (Failure Mode and Effects Analysis). It is also a good practice to do drills or simulations of emergencies in the MRI suite. You could simulate a cardiac or respiratory arrest or a fire in the MR unit. In any event, you should have periodic drills for some of the potential disasters, such as fires. We also noted an MRI suite safety calculator available online is a good place to start when you are looking at your MR safety program.
The VA health system has just published the results of an MRI safety audit they performed on 50 MRI suites in 43 of their facilities. They initiated this system wide audit in response to an event, described in detail later, that had taken place in one of their MRI units. All their units endorse the ACR guidelines and have policies generally consistent with those guidelines.
Overall, the units performed quite well but it is important to share with others those opportunities for improvement that they identified. The VA system is at the head of the pack when it comes to patient safety systems so you can bet that any issues they identified are likely to be present at most organizations.
There were four main areas identified for improvement. First had to do with training of personnel. This, of course, applies not only to the staff working directly in the MRI suite but also to any personnel that may need to enter the MRI suite. They require initial MRI safety training and then annual refresher training for all staff that may need to enter the MRI suite (eg. technologists, nurses, emergency response teams, etc.). They found evidence of training during orientation in 72% of such employees and evidence of annual training in 89% for those working for more than 2 years. One of the recommendations emanating from the audit is to develop standardized training modules (to ensure consistency of content) and to provide the training through an automated system (eg. online modules) to allow for monitoring compliance.
To those recommendations we add some of our own. Some hospitals, particularly those having behavioral health units, have separate emergency response teams for unruly patient events. You need to make sure that all the personnel you have identified to serve on those teams are identified as being in need of the MRI safety training and updates. Also, since the claustrophobia often seen in the MRI suite may lead to behavioral health patients suddenly decompensating, it is imperative that your MRI staff have appropriate training in the techniques used in behavioral health to de-escalate behaviors in such patients. And your periodic drills should therefore include not just ones for medical emergencies but also for behavioral health emergencies occurring in the MRI suite. And dont forget that there are multiple other personnel (eg. maintenance, housekeeping, your local firemen and policemen) that may need to enter the MRI suite at some time. Consider, in particular, including the fire and police personnel in some of your simulations and drills.
The second VA audit recommendation had to do with screening patients prior to MRI. They correctly point out that most serious incidents occurring in MRI suites have been due to deficiencies in screening methods or lack of strictly controlled access to MRI units. Each unit needs to utilize a screening form or checklist that includes all the devices, equipment, etc. that is not allowed in the magnet room. The MRI technologist who screens the patients is required to sign the screening form, which is then to be kept on record. Keeping that form as part of the medical record is valuable in the event that patient has to return for an emergent MRI at some time. The audit found the screening forms in 89% of cases, with technologist signatures in 82% and patient signatures in 78%. Also, when a potential contraindication to MRI is identified, documentation of the followup needs to be documented on the screening form. They found evidence of that in only 57% of cases.
The screening procedure is described in the ACR Guidance in detail. It talks about questions to be asked during screening, physical findings, screening techniques and procedures, who needs x-ray screening for potential ferromagnetic clips, implants, etc. It also discusses issues related to special circumstances such as pregnancy, patients needing sedation, patients needing accompaniment and other issues. No one could possibly confine to memory everything that must be considered during the MR screening process. Ferromagnetic materials may be present in things like tattoos, makeup, drug patches, unretrieved device fragments, and other places youd never suspect. Hence, good use of checklists is a must. And the list keeps changing. For example, the list of drug patches containing metal keeps changing (Hong 2010).
The third audit recommendation had to do with informed consent. VA policies require informed consent for us of contrast media in high-risk patients. They only identified 14 patients in this category but appropriate informed consent was completed in only 50% of those. It is important to have pre-screening in place to identify such high-risk patients and avoid contrast if possible. But where the potential benefits of a contrast examination outweigh the potential risks, appropriate informed consent should be obtained.
The fourth recommendation had to do with the physical environment in the MRI suite and emergency preparedness. Generally, all their units had appropriate signage to help prevent unauthorized or accidental access to MRI areas but actual physical barriers were present in only 80% of sites. Facilities are required to have direct visual observation of access corridors from their working positions and to be able to communicate two-way with patients who are in the scanner. Though it was a problem with the latter that led to the audit (see below), the audit showed high degrees of compliance with these requirements. However, they identified issues with the emergency call systems. Documentation of preventive maintenance of the call systems was found in only 82% and only 74% regularly tested their call systems. Use of drills was also suboptimal. Fire drills were conducted in only 64% and drills for medical or mental health emergencies were conducted in only 44%.
Interestingly, the VA audit of MRI safety was initiated after a 2008 incident (Report No. 08-01380-154) in which a patient crawled out of an MRI scanner after his calls for help went unheeded because the panic button was inoperable and no maintenance checks had been done on the intercom system or the panic button. That, of course, is reminiscent of one of the earliest patient safety events that was memorialized in Steven Caseys Set Phasers on Stun (Casey 1993). The 2008 VA incident also illustrates another serious error we have frequently commented upon in the past the volume on the intercom system was frequently turned down by staff because of excessive noise (see our Patient Safety Tips of the Week for March 5, 2007 Disabled Alarms, and February 23, 2010 Alarm Issues in the News Again).
Every facility that performs MRI imaging needs to have an audit process in place to ensure compliance with safety measures. That audit should also include consideration of other vulnerabilities in the radiology suite in general, such as medication errors, anesthesia/sedation, infection control etc.
Prior columns on MRI safety:
Joint Commission. Sentinel Event Alert. Preventing accidents and injuries in the MRI suite. Issue 38. February 14, 2008
Kanal E et al. ACR Guidance Document for Safe MR Practices: 2007. AJR 2007; 188: 1-27 http://www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx
Department of Veterans Affairs Office of Inspector General. Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities. Report No. 09-01038-77. January 26, 2011
Hong I, Gabay M, Lodolce A. Safety concerns involving transdermal patches magnetic resonance imaging [MRI]. Hosp Pharm 2010; 45(10): 771778
Report No. 08-01380-154. Department of Veterans Affairs Office of Inspector General. Healthcare Inspection Alleged Patient Neglect During a Magnetic Resonance Imaging Exam Michael E. DeBakey VA Medical Center Houston, TX. Report No. 08-01380-154. June 27, 2008
Casey S. Set Phasers on Stun and Other True Tales of Design, Technology, and Human Error. Santa Barbara California: Aegean Publishing Company, 1998 (first published in 1993)
Print MRI Safety Audit
February 8, 2011
Inducing Too Early
The Leapfrog Group, in conjunction with multiple partners, has issued a Call to Action to address the striking increase in the number of deliveries being induced prior to 39 weeks without compelling medical indications. Their call to action is accompanied by public release of results of induction rates at 773 hospitals nationwide in their 2010 hospital survey. And, through their partnerships with groups like the March of Dimes, the Childbirth Connection, and the California Maternal Quality Care Collaborative they have made available a number of excellent resources to help hospitals and communities address this growing problem. And the programs are endorsed by a whole host of professional groups.
Despite ACOG guidelines for criteria for inductions and C-sections at gestational age <39 weeks, there has been a relentless increase in the number of induced labors and elective C-sections over the last 2 decades.
If you are like most hospitals or healthcare organizations, you may not readily know your rates for inductions prior to 39 weeks of gestation. They should be part of your quality improvement program. Even those organizations that do include the rates as measurement indicators may not have a breakdown by reason for early induction. So if you dont know today, you better get started now.
The March of Dimes site provides a downloadable Less than 39 weeks toolkit that was developed by the March of Dimes, California Maternal Quality Care Collaborative and the California Department of Public Health; Maternal, Child and Adolescent Health Divisions, plus a clinician slide deck presentation, and resources for mothers, families, and the public.
They begin by making a compelling case for avoiding induction of labor prior to 39 weeks when no clearcut medical indication exists. The provide the evidence base that clearly shows increases in a host of complications in neonates delivered prior to 39 weeks and that there appear to be no ill effects on mothers by waiting (for those mothers lacking the conditions specified under indications for early induction). Neonates delivered prior to 39 weeks have higher rates of NICU admissions, respiratory distress syndrome, transient tachypnea of the newborn, ventilator use, sepsis, hypoglycemia and feeding problems. They emphasize that the brain is still undergoing tremendous growth and maturation during weeks 35 to 40 and other organs are also maturing in those final weeks. They also note that even a mature lung profile on amniocentesis does not rule out respiratory difficulty after early induction.
Barriers to reducing rates of early inductions without medical indications include attitudes of both clinicians and patients. Prospective mothers may often look to a scheduled induction because of travel distance to the hospital, desire to have their own obstetrician deliver their baby, desire to be done with being pregnant, and a general perception that there is no harm in early induction. The two most frequently noted clinician barriers are (1) the widely held perception that there is little or no harm to the baby or that there is increase risk of harm to the mother and (2) the convenience factor. But other barriers to developing a program to reduce early inductions include time and staff limitations. Hospital leadership must ensure that adequate time is made available for staff to participate in the learning, planning and implementation activities required for a successful implementation. And, lastly, mothers and communities at large must be made aware of the potential harms of early inductions and the benefits to babies of waiting for more gestational maturity.
The clinician slide deck presentation is actually quite good at laying out the evidence base against early inductions and discussing both patient and physician perceptions about early inductions.
The Less than 39 weeks toolkit contains specifications for medical conditions that may justify a scheduled delivery prior to 39 weeks of gestation from ACOG, Joint Commission, the National Quality Forum, and Leapfrog.
They also stress the importance of using appropriate criteria for determination of gestational age. Gestational age should be confirmed using one of the ACOG criteria:
The resources provide descriptions of quality improvement projects on early inductions that were successfully implemented at Magee Womens Hospital (in Western Pennsylvania), Intermountain Healthcare, and the Ohio Perinatal Quality Collaborative and hospital case studies from Pamona Valley Hospital Medical Center (California) and Tallahassee Memorial Hospital (Florida). They provide examples of tools utilized in those implementations and a good description of the barriers and challenges met. The tools include samples of forms that can be used at the time of scheduling elective inductions or C-sections and sample policies for hospitals to adopt. The fact that these hospitals and health systems have been able to implement these programs so successfully are examples to others that this can be accomplished. Keys are having good interdisciplinary teams, strong physician and nursing leadership, good data with trending and frequent feedback, plus good awareness and educational programs for professionals, patients, and the community at large. The Childbirth Connection website also has some excellent materials for mothers and professionals.
Informed consent should include a discussion about both the benefits and risks any time an early induction is scheduled. The Less than 39 weeks toolkit provides some examples of informed consents for labor induction.
The Less than 39 weeks toolkit also provides good discussion on data collection tools, measurement indicators, trend charts, quality improvement and PDSA cycles, and other useful things youll need in your implementation.
Ultimately, pressure from the public to optimize labor induction practices may help change the current pattern. The Leapfrog press release was accompanied by publishing of the hospital rates of early induction by state. Leapfrog and its collaborating organizations hope that prospective mothers and families will inquire about rates of early induction when choosing their providers and hospitals. The Less than 39 weeks toolkit includes some very good informational materials for mothers and families and the general public.
The Leapfrog Group (press release). Newborn Deliveries Are Scheduled Too Early, According to Hospital Watchdog Group. Leapfrog Announces Call to Action: Protect Mothers and Babies from Unnecessary Harm. January 26, 2011
The Leapfrog Group. Hospital rates of early delivery by state.
March of Dimes. Medical resources. Less than 39 weeks toolkit.
Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, and Kowalewski L. Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08-85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; First edition published by March of Dimes, July 2010.
March of Dimes, California Maternal Quality Care Collaborative and the California Department of Public Health; Maternal, Child and Adolescent Health Divisions. Less than 39 weeks toolkit.
clinician slide deck presentation
Print Inducing Too Early
February 15, 2011
For many years now we have had a focus on DVT prophylaxis as a patient safety issue. Measures of DVT prophylaxis in surgical cases have been parts of the SCIP project and other core measure systems used by many third party payors. There has even been some movement to expand the role of DVT prophylaxis on the outpatient side (see our December 1, 2009 Patient Safety Tip of the Week Patient Safety Doesnt End at Discharge and our December 2009 Whats New in the Patient Safety World column More on Ambulatory DVT Prophylaxis).
Now the pendulum may be starting to swing in the other direction. The DVT risk varies considerably by type of surgery and is also very dependent upon other risk factors that a patient might have. Even the evidence base for use of DVT prophylaxis varies considerably by type of surgery. For many orthopedic surgeries there is a very robust evidence base of high quality studies demonstrating the value of DVT prophylaxis. But the evidence base in other types of surgery may not be as compelling.
Now a new paper by some very respected investigators in the surgical quality improvement field (Qadan 2011) has questioned the current recommendations on venous thrombembolism (VTE) prophylaxis in elective major surgery. The authors collected data on DVT and PE in patients electively undergoing 4 major surgical procedures (colorectal resection, total knee replacement, total hip replacement, and hysterectomy) from a large database from a consortium of academic medical centers for two periods of time (2003-2004 vs. 2007-2008). The study demonstrated a substantial increase in the use of pharmacologic DVT prophylaxis between the two time periods. Yet the rates of DVT and PE were not significantly impacted by this increased use of such prophylaxis. Moreover, the overall rates of DVT and PE were actually quite low and the rates in patients who did not receive pharmacoprophylaxis actually decreased between the two time periods. The authors conclude that this may show that clinical judgment of physicians in choosing which patients need pharmacoprophylaxis is remarkable.
Unfortunately, the study did not have available data on complications of pharmacoprophylaxis (such as hemorrhage, heparin-induced thrombocytopenia, etc.) which might show that the net benefit of prophylaxis may be even lower.
One of the most striking revelations of this paper is that the overall rate of VTE in this elective surgery population is quite low (0.6% to 3.2%). One of the biggest areas of controversy in all prior investigations on VTE has been the means by which DVT is diagnosed. Most randomized controlled trials have used ultrasound techniques to look for evidence of DVT. Many have argued that such techniques artificially increase the incidence and prevalence of DVT by including many cases that will never be clinically relevant. The authors point out industry funding of studies that may overestimate the true VTE rate. They point out that the number needed to treat (NNT) to prevent a single PE in the elective surgical population is about 125 and an even higher NNT would apply to fatal PE. (We, of course, would argue that even one fatal PE is one too many.)
But their point is very well taken. Over the past 5 years we have seen recommendations for aggressive preventive measures in a variety of areas (perioperative beta blockers, tight glucose control, antibiotics for CAP within 4 hours, etc.) all come under fire upon further review. What this study does is put the numbers in perspective and challenge us to take a closer look at the real evidence base for VTE prophylaxis. Most would agree that the decision about VTE prophylaxis should be individualized based upon both patient risk factors and risk factors inherent in the surgical procedure. What we really need is a better understanding of how to more accurately assess the risks based upon analysis of such factors at the individual level.
The current ACCP Evidence-Based Clinical Practice Guidelines on VTE prophylaxis (Geerts 2008) state based on the results of numerous randomized clinical trials and metaanalyses, the routine use of thromboprophylaxis is recommended following major general surgical procedures. And those guidelines grade the supporting evidence as Grade 1A, the highest level, for prophylaxis with low-dose unfractionated heparin, low molecular weight heparins (LMWH), or fondaparinux. Yet many of the studies in that evidence base had DVT and PE rates much higher than seen in the Qadan study.
We think the provocative new study by Qadan et al will rekindle the debate about prophylaxis in this patient population. Many of our current pay-for-performance (P4P) systems may be driving the use of pharmacoprophylaxis in all surgical patients. The authors also point to another recent study (Huseynova 2009) that challenged the use of VTE as a marker of quality of care in trauma patients.
So we dont think weve heard the end of this story
Note also that an interesting recent observation by University of Colorado investigators (Lowry 2011) may also impact the choice of DVT prophylaxis in surgical patients, After seeing anecdotal evidence that patients who had undergone major abdominal surgery did better overall on low-dose heparin infusions than subcutaneous heparin regimens and had no untoward side effects, they studied details of the pharmacoprophylaxis regimens. Most of the patients in the study had cancer and were in the ICU. Most of the patients receiving heparin by the subcutaneous route had hypercoagulable profiles for up to 5 days after surgery but those receiving intravenous heparin had normal profiles. They conclude that perhaps subcuanous heparin prophylaxis may not be the best route for prophylaxis in this patient population but recommend this issue be addressed in a larger randomized controlled trial.
Qadan M, Polk H, Hohmann S, et al. A Reassessment of Needs and Practice Patterns in Pharmacologic Prophylaxis of Venous Thromboembolism Following Elective Major Surgery. Annals of Surgery 2011; 253(2): 215-220, February 2011
Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of Venous Thromboembolism. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133(6 suppl): 381S-453S
Huseynova K, Xiong W, Ray JG et al. Venous Thromboembolism as a Marker of Quality of Care in Trauma. J Am Coll Surg 2009; 208: 547-552
Lowry F. Subcutaneous Heparin Not Adequately Absorbed After Abdominal Surgery. Medscape 2011; January 19, 2011
February 22, 2011
We have written multiple columns on problems related to alarms. One year ago we did an extensive update after an alarm-related death in Boston (see our February 23, 2010 Patient Safety Tip of the Week Alarm Issues in the News Again). Last week the Boston Globe ran an excellent series (Kowalczyk 2011a, Kowalczyk 2011b) on problems related to alarms and especially the problem of alarm fatigue.
The Globe series focuses on alarm fatigue and efforts to reduce the number of alarms and, hence, the number of false alarms. It describes efforts that hospitals are implementing to prevent purposeful disabling of alarms and staffing changes to ensure alarms are heeded. It also discusses nascent efforts to develop alarm systems (smart alarms) that integrate multiple types of physiologic measurements to help better differentiate true emergencies from artifact.
But it is important to keep in mind that alarm fatigue is not the only problem that leads to patient harm when alarm systems are misused. Equally important is overreliance on alarms. All too often the critical clinical observation of patients takes a backseat because physicians and staff think the alarm will alert me if there is a problem.
A provocative article (Lynn 2011) on alarms and their failure to identify deteriorating patients early was also just published. The authors 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. This is a fascinating perspective on identifying deteriorating patients early and, though it is a hard read at times, is well worth your time.
The first pattern of unexpected death is the most common and is typical of the deterioration seen in conditions like sepsis, CHF, and pulmonary embolism. Respiratory alkalosis develops. While this is usually due to an increase in respiratory rate, it is also due to an increase in tidal volume and seldom does the respiratory rate exceed common thresholds set (such as rates of 30/minute) for triggering alarms. Also, the changes in minute volume and the respiratory alkalosis shifting the oxyhemoglobin curve tend to keep oxygen saturations at high levels until late in the course. Hence, even continuous pulse oximetry may fail to alert providers to deteriorating clinical conditions and may lead to a false sense of security.
The authors also have a good discussion of how the commonly used, but arbitrary, threshold of 90% for oxygen saturation came about and became perpetuated.
The second pattern of deterioration they note is the classic CO2 narcosis. As CO2 rises one sees further central depression of respiration and a vicious cycle. However, as we have pointed out previously, it is not just respiratory rate that slows and it is notoriously difficult at the bedside to predict who is hypoventilating. The authors also note that in some cases benzodiazepines may suppress tidal volumes and respiratory rates may actually increase. This is a pattern for which we have advocated using a combination of sedation scales and capnography. However, the authors point out that such monitoring may be inadequate because many of these cases are complicated by the third pattern described below. The important point is that there may be a huge difference when the patient is awake and when he/she is asleep.
The third pattern is one that is typically seen in sleep apnea. In this pattern one sees repetitive reductions in airflow and oxygen saturation during sleep followed by arousals. The arousals rescue the patient but eventually the capacity or reserve of the patient to recover with arousals becomes impaired (often in response to narcotics or sedatives) and the patient may experience sudden death during sleep. The authors discuss the inability of currently used oximeters to recognize this pattern. They even imply that this pattern may give rise to oximeters alarming and being interpreted as false alarms attributed to motion artifact, etc. because when staff respond to the alarm the patient is now awake, breathing normally and has a normal oxygen saturation.
Warnings about this third pattern become even more concerning given the significant percentage of patients being admitted who are at risk for sleep apnea (see our Whats New in the Patient Safety World columns for November 2010 More on Preoperative Screening for Obstructive Sleep Apnea and July 2010 Obstructive Sleep Apnea in the General Inpatient Population).
In both the second and third patterns, use of supplemental oxygen may mask the deterioration, provide a false sense of security, and delay critical responses to a deteriorating clinical situation. Hence, its important not to use oxygen unless there is a legitimate indication for its use (see our January 4, 2011 Patient Safety Tip of the Week Safer Use of PCA).
The authors go on to discuss the flaws in current threshold-based alarm systems and the need for true smart alarms that integrate multiple physiological parameters and respond to patterns of changes in these. This article provides tremendous insight into why the concept of rapid response teams has proven disappointing to date. As we have mentioned in several of our own columns on rapid response teams, the problem is not with the response teams. Rather it is with our poor recognition of early clinical deterioration.
Checking alarms should be a regular component of your Patient Safety Walk Rounds. More importantly, it should be something your staff does daily on every unit that utilizes alarms of any type. Some units even do it on every shift. You should at least include alarm status as part of your structured handoff tool used at changes of shift. We also strongly recommend that any time you set up a new piece of equipment on a patient you use a checklist specific to that piece of equipment that forces you to verify that all alarms are appropriately set and functional and that parameters chosen are appropriate. We also recommend you review some of the useful tips weve included in our February 23, 2010 Patient Safety Tip of the Week Alarm Issues in the News Again and the several other columns noted below.
And if you are considering doing a FMEA (Failure Mode and Effects Analysis) on one or more of your alarm systems, an excellent resource is Fault Tree Analysis of Clinical Alarms (Hyman 2008). This is a great way of looking at the potential things that can go wrong, both technical and human, in each of multiple facets of any alarm system.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
Prior Patient Safety Tips of the Week pertaining to early recognition of clinical deterioration:
Prior Patient Safety Tips of the Week pertaining to PCA and postoperative respiratory depression:
Kowalczyk L. For nurses, its a constant dash to respond to alarms. (first of two parts)
Boston Globe February 13, 2011
Kowalczyk L. No easy solutions for alarm fatigue. (second of two parts).
Boston Globe February 14, 2011
Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11February2011)
Hyman WA, Johnson E. Fault Tree Analysis of Clinical Alarms. Journal of Clinical Engineering 2008; 33(2) 85-94
Print Rethinking Alarms
March 1, 2011
Tests Pending at Discharge
A new systematic review on the safety implications of missed test results in hospitalized patients has just come out (Callen 2011). This is an issue we have harped upon in many previous columns and the findings in the new review are no less frightening. They found lack of followup on test results ranged from 20-60% for inpatients and 1-75% for emergency room patients. And the lack of followup had clinical implications since some of the results were considered critical or urgent or otherwise actionable.
A second recent paper described lessons learned from implementation of a computerized application for tracking pending test results at discharge at Partners Healthcare in Boston (Dalal 2011). After implementation a survey was sent to multiple potential users of the system and results of use of the application were disappointing. Almost half the respondents never used the application and most of the others used it only 1-2 times per week. Barriers to use included not having enough time, being inundated with irrelevant results, not fitting into the workflow, and getting results on patients not belonging to them. Most, however, agreed that a well-designed computerized application could be valuable in helping manage test results at discharge. Being able to prioritize or filter which test results they want to see was important.
The issue of attribution of a patient to a physician is harder than it sounds. Tests may originally be ordered in the ER prior to the decision to admit. In such cases the ER physicians name may be attached to such tests. The patient then gets admitted under one attending or hospitalist but those physicians may also change during the course of a hospitalization. Yet tests they ordered may be attributed to them. The situation gets even more complicated in academic medical centers where multiple housestaff are involved in care. Ultimately you want all test results to come back to the attending of record at the time of discharge so that he/she can identify pending tests results and note them in the discharge summary. It also needs to be made clear who will be responsible for following up on those pending test results. We always recommend that be discussed in a phone call at the transition of care but that is not always possible. But it is important. In our March 9, 2010 Patient Safety Tip of the Week Communication of Urgent or Unexpected Radiology Findings we noted a study (Were et al 2009) which showed that only 16% of tests with results pending actually are documented in discharge summaries. They identified multiple changes in attendings as an issue and difficulty identifying the physician who will ultimately follow the patient after discharge. We also noted in our October 13, 2009 Patient Safety Tip of the Week Slipping Through the Cracks that studies have shown sending reports to two physicians, rather than increasing the likelihood someone will follow up, actually doubles the risk that no one will follow up (Singh 2009)!
While technological solutions are likely to be of benefit, to date there is scant evidence that they have had a significant impact on this problem. The Callen paper notes that having an online endorsement or acknowledgement feature would at least help organizations better track how important test results are being communicated.
Suffice it to say that the ideal system for ensuring followup of all test results remains elusive.
See also our other columns on communicating significant results:
Callen J, Georgiou A, Li J, Westbrook JI. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf 2011; 20: 194-199 Published Online First: 7 February 2011
Dalal AK, Poon EG, Karson AS, et al. Lessons learned from implementation of a computerized application for pending tests at hospital discharge. Journal of Hospital Medicine 2011; 6(1): 16-21 (first published online November 15, 2011)
Were MC, Li X, Kesterson J, et al. Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers. Journal of General Internal Medicine 2009; 24(9): 1002-1006
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med.2009; 169(17): 1578-1586.
March 8, 2011
Yes, Physicians Get
Weve written multiple columns on the impact of interruptions and distractions on nursing and pharmacy and their relation to errors (see list at end of this column). In many cases physicians are the source of the interruptions. In fact, when a Do Not Disturb sign was piloted to assist medication administration by nurses (Pape 2005), all sorts of interruptions decreased with one exception: interruptions by physicians!
But physicians are also commonly on the receiving end as well they are often being interrupted and those interruptions may lead to failure to return to tasks and other errors.
Carey Chisholm, MD and colleagues have written about the occurrence of interruptions on physicians for over a decade and have just published a new study on their occurrence in the emergency department setting (Chisholm 2011). The performed a time-motion study at 2 urban academic and 2 community emergency departments. Two-hour observation periods with 85 emergency physicians were included. They found that about half of each time period was spent on indirect patient care (eg. charting, reviewing test results, interacting with consultants, nurses, housestaff, etc.). Emergency physicians in the academic centers spent only 36 minutes of each two-hour period on average in direct patient care (those in community settings spent 41 minutes of each two-hour period on average), which included not only direct patient contact but also ordering tests and medications, doing procedures, or interpreting EKGs. The remainder of the time was classified as personal and accounted for 6 minutes in the academic settings and 13 minutes in the community settings. All physicians cared for multiple patients simultaneously (median 5 for academic, 6 for community) but all experienced surges where they care for many more simultaneously. The median number of interpersonal interactions per two-hour period was 70 for academic physicians and 65 for community physicians.
So its pretty obvious that emergency physicians are both busy and multitasking and it should come as no surprise that they would experience interruptions frequently. Chisholm and colleagues found that emergency physicians in academic sites experienced a median of 12 interruptions per period and those at community sites a median of 6 interruptions per period. Of the interruptions, almost half resulted in breaks in task. These are interruptions that result in changing tasks. The authors note that both the times spent in direct and indirect patient care and the frequency of interruptions have changed little since they did similar surveys a decade ago (Chisholm 2000). That previous work had also shown that both the number of interruptions and breaks in task increased with the average number of patients being managed simultaneously.
Breaks in task are especially important because one may never return appropriately to the previous task. Even when using checklists (whether in healthcare or aviation or other industry) breaks in task may result in steps of a sequence being skipped or overlooked. That is one of the reasons that during critical activities pilots use the sterile cockpit concept and nurses or pharmacists use a similar concept wherein they flag themselves in some manner to prevent interruptions. In fact, a healthcare study done in Australia (Westbrook 2010a) showed that physicians failed to return to tasks 18.5% of the time after interruptions.
In the Westbrook study, 11% of tasks were interrupted (and 3.5% were interrupted more than once). The total time for tasks increased with interruptions. But, interestingly, when the authors corrected for a length of time of observation bias, they found that interrupted tasks were actually completed in shorter times! They speculated that physicians may be catching up for lost time. We would anticipate that such shortened duration tasks, rather than being examples of improved efficiency, might actually be especially prone to errors and omissions.
Another study of emergency physicians (Friedman 2005) showed emergency physicians at Toronto General Hospital were interrupted every 13.8 minutes on average (4.4 interruptions per hour) and that the rate of interruptions increased with increasing shift intensity. Half the interruptions were from nurses and a third from other physicians. While most interruptions did not require the physician to move to a new location, about 10% did require a move.
Some studies have shown phone calls and pages to be the most frequent type of interruption (Weigl 2011). Perhaps some of those could be avoided by making patient information available to the callers via other means. Of the face-to-face interruptions, it is not known how many involve patient care but Friedman et al. note that often the interruptions are of a personal or administrative nature rather than being related to patient care.
Emergency physicians were interrupted nearly three times more often than primary care physicians (Chisholm 2001) and experienced significantly more care interruptions, nonpatient interruptions, telephone interruptions, and breaks in tasks.
Another study (Jeanmonod 2010) showed that emergency physicians are interrupted more often in certain activities than others. For example, they were interrupted during charting or reviewing data about 50% of the time. Bedside interruptions were less common (26%) but had a negative impact on patient satisfaction. The majority of interruptions were initiated by another physician or nurse. Unlike the above studies, these authors found physicians rarely changed tasks after an interruption.
The most recent Chisholm study was based on data collected in 2006 so there remain unanswered questions about the impact of new technologies on interruptions. It might be anticipated that more widespread availability of CPOE and electronic medical records might reduce many of the interruptions related to obtaining patient-related information, such as telephone calls. However, those same technologies may introduce other types of interruptions (eg. overzealous use of rules-based alerts and reminders, need to fumble through multiple screens, etc.). And the impact of text messaging is unknown. While focused use of text messaging could conceivably promote asynchronous communication that might be expected to reduce interruptions, experience in the real world outside of healthcare suggests that text messaging creates far more interruptions and distractions.
The concept of the no interruption zone that is commonly used by pharmacists during medication preparation or by nurses during medication administration may also be used for physician activities in certain settings. Bright yellow laminated signs were used at a New Mexico hospital to ensure that no one entered patient rooms during central line insertion (Hill 2010).
Our August 25, 2009 Patient Safety Tip of the Week Interruptions, Distractions, InattentionOops! highlighted some excellent studies on interruptions and distractions in healthcare. In that we provided references to some good statistics about the frequency and nature of interruptions and distractions and listed some recommendations about how to avoid them. We also discussed some of the cognitive research on how memory works and how interruptions affect what stays in your working memory, a key concept in error occurrence. Our May 4, 2010 Patient Safety Tip of the Week More on the Impact of Interruptions cited an excellent article on the impact of interruptions on medication administration errors (Westbrook 2010b). That article also had a good discussion of strategies to minimize interruptions and future directions for research on reducing the occurrence of interruptions.
Prior Patient Safety Tips of the Week dealing with interruptions:
Pape TM, Guerra DM, Muzquiz M, et al. Innovative Approaches to Reducing Nurses Distractions During Medication Administration. Journal of Continuing Education in Nursing 2005; 36(3): 108-116 May/June 2005
Chisholm CD, Weaver CS, Whenmouth L, Giles B. A Task Analysis of Emergency Physician Activities in Academic and Community Settings. Ann Emerg Med 2011; published ahead of print January 31, 2011
Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency Department Workplace Interruptions Are Emergency Physicians Interrupt-driven and Multitasking? Academic Emergency Medicine 2000; 7(11): 12391243
Chisholm CD, Dornfeld A, Nelson DR, Cordell WH. Work interrupted: A comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med 2001; 38(2): 146-151
Westbrook JI, Colera E, Dunsmuir WTM, et al. The impact of interruptions on clinical task completion. Qual Saf Health Care doi:10.1136/qshc.2009.039255
Friedman SM, Elinson R, Arenovich T. Emergency Physician Work, Communication and Interruptions: A Human FactorsApproach. Israeli Journal of Emergency Medicine 2005; 5(3): 35-42
Weigl M, Mller A, Zupanc A, et al. Hospital doctors' workflow interruptions and activities: an observation study. BMJ Qual Saf qshc.2010.043281Published Online First: 6 January 2011
Jeanmonod R, Boyd M, Loewenthal M, Triner W. The nature of emergency department interruptions and their impact on patient satisfaction. Emerg Med J 2010; 27: 376-379
Hill P. What is the initiative? CLABSI Prevention: Assure no one entered the patient room during a bedside central line insertion. New Mexico Hospital Association. Patient Safety Newsletter. January 2011
Westbrook JI., Woods A, Rob MI., Dunsmuir WTM, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine. 2010, 170(8): 683-690.
March 15, 2011
Early Warnings for Sepsis
A few columns ago we talked about our difficulties in early detection of patient deterioration (see our Februrary 22, 2011 Patient Safety Tip of the Week Rethinking Alarms). We highlighted a very insightful study by Lynn et al (Lynn 2011) that described many of the flaws in current patient monitoring systems, particularly those monitoring for respiratory complications. And we stressed the need for smart alarm systems that can monitor multiple parameters in an integrated fashion to detect deterioration earlier.
Much of the work looking for such smart early warning systems has focused on sepsis. Over the past few years the Surviving Sepsis Campaign has focused on improving morbidity and mortality from sepsis. Timely antibiotics and goal-directed therapy, with adequate fluid rescuscitation are critical components in management of sepsis. The Surviving Sepsis Campaign recommends a group of interventions, each of which has some evidence base, delivered as a bundle. Compliance with all the elements of the bundle has been associated with sustained reduction in mortality from sepsis in multiple sites (ICU, ER, med/surg wards) (Levy 2010). In medical and surgical ICUs compliance with the bundles was associated with not only improved mortality but also with reduced ICU and total hospital length of stay (Castellanos-Ortega 2010).
Studies have demonstrated that earlier antibiotic therapy confers a mortality benefit. The Surviving Sepsis Campaign protocols focus on delivery of antibiotics within 3 hours of an emergency department admission and one hour of a non-emergency department admission. One study confirmed the impact on mortality of antibiotic administration in the emergency department within the first hour (Gaieski 2010).
Less is known about the impact of the bundles on patients who develop sepsis on the medicine and surgical wards of the hospital. One of the major problems is that there is often a delay in recognition of the sepsis syndrome. Thats where the concept of an early warning system becomes important. Theoretically, earlier recognition of evolving sepsis should lead to earlier therapies and better outcomes.
Investigators at Barnes-Jewish Hospital in St. Louis have just published some preliminary results of a system of real-time computerized alerts for possible sepsis in non-ICU patients (Sawyer 2011). Through review of prior cases the same group of investigators had derived and validated a real-time computerized prediction tool (Thiel 2010). That tool contains both information from vital signs monitoring and a variety of laboratory parameters. When the prediction tool identified a patient on the medicine ward with possible sepsis, an alert was sent automatically (via text page) to the charge nurse on that ward. That nurse would then assess the patient and notify the covering physician, who would decide on any further course of action. Their results showed that patients in the intervention group were more likely to have an increased rate of interventions (such as antibiotic escalation, fluid therapy, oxygen, cultures and other diagnostic tests, etc.) within 12 hours than the nonintervention group. Though both groups had the same rate of transfer to the ICU, those in the intervention group were transferred earlier on average. However, there was no difference in mortality or total hospital length of stay between the two groups, though this pilot study was underpowered to show any such difference.
Consider this study a proof of concept study. It basically shows that a smart computerized monitoring and alerting system is capable of recognizing patients with a potentially deteriorating condition early and getting staff to respond earlier than they would otherwise. The next step obviously is to do a randomized controlled trial using similar methodology to a much larger patient population. But the idea is a good one and the number of clinical conditions to which similar methodologies might be applied is large.
The concept of track and trigger early warning systems is not new. In our December 29, 2009 Patient Safety Tip of the Week Recognizing Deteriorating Patients we discussed MEWS (the modified early warning score). MEWS was a good start to the concept that monitoring multiple parameters simultaneously and integrating them to provide a bigger picture might be potentially valuable. MEWS began as a paper-based system but with the introduction of more sophisticated physiologic monitoring systems and more widespread us of electronic medical records, the concept of rules-based algorithms running in the background and generating alerts to clinicians has become a reality. Expect much more on such systems over the next few years but be wary of adopting them on a widespread basis before they have been shown to impact hard outcomes, not just process measures that are proxies of potential outcomes.
Of course, remember that the best way to reduce mortality from sepsis is to avoid sepsis in the first place! If you have good patient safety programs in place to avoid some of the hospital-acquired conditions that may serve as precursors of sepsis, such as catheter-associated UTIs (CAUTIs), ventilator-associated pneumonias (VAPs), and catheter-associated bacteremias (CLABSIs), youll find that your overall incidence of hospital-acquired sepsis should decrease.
Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11February2011)
Surviving Sepsis Campaign. Website.
Levy MM, Dellinger RP, Townsend SR, et al. on behalf of the Surviving Sepsis Campaign. The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Critical Care Medicine 2010; 38(2): 367-374
Castellanos-Ortega A, Suberviola B, Garca-Astudillo, Luis A, et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: Results of a three-year follow-up quasi-experimental study. Critical Care Medicine 2010; 38(4): 1036-1043
Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010; 38(4): 1045-53
Sawyer AM., Deal EN, Labelle AJ, et al. Implementation of a real-time computerized sepsis alert in nonintensive care unit patients. Critical Care Medicine 2011; 39(3): 469-473
Thiel SW, Rosini JM, Shannon W, et al. Early prediction of septic shock in hospitalized patients. J Hosp Med 2010; 5(1): 19-25
March 22, 2011
An EMR Feature Detrimental
to Teamwork and Patient
The current issue of the Journal of the American Medical Informatics Association (JAMIA) contains some studies showing some very positive outcomes related to electronic medical records (EMRs). But it also contains one study that verifies a feature of the EMR we find disturbing and potentially a setback in time. We have lamented in the past that one of the drawbacks of EMRs is that they often dont allow the big picture to be readily conveyed to everyone (see our August 26, 2008 Patient Safety Tip of the Week Pattern Recognition and CPOE). Now there is another feature commonly encountered in the EMR that is a throwback to a prior era.
The article in this months JAMIA we are referring to is one that looked at who writes notes in the EMR and, more importantly, who reads them (Hripcsak 2011). The authors used the detailed audit logs of EMRs to determine the frequency of notes by various members of the healthcare team, the time spent entering such notes, the frequency with which those notes were accessed, and the distribution of types of healthcare workers accessing those notes. They found substantial variation by user type in the time spent entering notes into the EMR. Overall, most users averaged less than 90 minutes per day authoring notes and 30 minutes per day viewing others notes.
But the most striking numbers deal with viewing the notes. While attending notes and resident notes were viewed 97% and 99% of the time, that was not the case for notes authored by other members of the healthcare team. In particular, fewer than 20% of nursing notes were read by attendings and residents and only 38% of nursing notes were read by other nurses. Note that nurses have several other means of communicating with each other (standardized handoffs, etc.). Hopefully information from nursing was also communicated to physicians when nurses are included in daily rounds as well.
And 16% of all notes were never read by anyone!
This seems like a journey into the past! For the longest time, hospitals were divided in how they partitioned the medical chart. Some hospitals kept notes by physicians, consultants, nurses, therapists, dietitians, etc. segregated from each other whereas other hospitals intermingled all the notes in the progress note section. We can recall medical staff meetings where some disgruntled physicians indignantly ranted Im not interested in seeing the *#!&ing social work note. Generally, as the value of teamwork became increasingly appreciated and a culture of safety adopted, most organizations migrated toward the intermingled model.
But with the advent of the EMR we have seen a trend back to the partitioned model. The statistics above mean that most physicians seldom read notes by anyone other than physicians. No wonder we have so many adverse events where communication breakdowns are identified as root causes or contributory factors.
Some of the problem may be related to the newness of the EMR. Most EMRs do allow some degree of customization of what is displayed and how and where it is displayed. So a user might choose to keep all clinical notes together or to sort them by provider type. In some cases, the default setting is the partitioned one and the physician may not even realize he/she can choose the intermingled model.
And, of course, we really have no idea of how often notes were read in the paper chart. Just because the notes of various healthcare workers were intermingled does not mean they were actually read. Undoubtedly some physicians were blind to the notes above their own daily progress notes if they were written by someone other than themselves. We know that from reviewing charts and seeing notes that omitted important information from those previous notes or even contradicted what was in those previous notes. But we also know that physicians are generally more likely to read nurses notes (or notes of other healthcare workers) if they are intermingled with their own notes.
The Hripcsak study only looked at specific notes in the EMR. It did not assess the frequency that users looked at graphically represented information such as vital sign charts, I&O charts, or other flow charts. Well bet youd be surprised at how few times those are accessed in the EMR as well.
Aside from the impact on teamwork and quality and patient safety, think of the potential liability issues from failure to read nursing notes on your patients. Doctor, why didnt you know the patient was complaining about ___? The nurses notes clearly state he complained about ___ daily. Try explaining that to a jury in a malpractice hearing!
In the Hripcsak study there was also a disparity between medical residents perceptions of the time they spent documenting in the EMR and that which was recorded by the audits. Whereas two thirds of medical residents in surveys felt they spent over 4 hours daily writing chart notes, the audits found they spent about 65 minutes per day on average entering medical notes into the EMR.
So while the audit tools were incorporated into the EMRs primarily to provide surveillance for HIPAA privacy-related issues, they do provide other potentially valuable information about our daily workflows and interactions with other members of the healthcare team. Its even conceivable that someday we might be able to use parameters like those in the Hripcsak study as proxies for measures of teamness.
We are concerned that such a potentially valuable innovation as the EMR might inadvertently be causing a regression to an old model that denigrated the value of the entire team. The EMR should theoretically improve communication between healthcare workers, not create barriers to such communication. Designers of EMRs need to consider ways to string together multiple progress notes from various healthcare workers in a correct time sequence. Most current EMRs typically require the user to click into one progress note, then click out, search for another note and click into that note. That obviously reduces the likelihood that one user will look at the notes from other members of the healthcare team.
We encourage you to take a look at the way clinical documentation is displayed in your EMR and whether you can change that display. Also consider using your audit tools to see how often each member of your healthcare team pays attention to the work of other members of that team.
Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. Use of electronic clinical documentation: time spent and team interactions. JAMIA 2011;18:112-117
March 29, 2011
The Silent Treatment:
A Dose of Reality
In our January 2011 Whats New in the Patient Safety World column No Improvement in Patient Safety: Why Not? we lamented the relative lack of progress we have made in reducing the number of harmful patient events. In that article we did discuss some of the reasons, including implementation of some evidence-based interventions that turned out to be not-so-evidence-based, unintended consequences of other interventions, etc. However, we ascribed much of the problem to our failure to significantly change the culture of safety.
When we do root cause analyses (RCAs) three themes always make their way to the top of almost every one we do: (1) communication issues (2) failure to heed alarms and (3) failure to buck the authority gradient. Of course, all three have their roots in the culture of safety or, rather, the lack of a culture of safety.
Last week a very valuable contribution to patient safety came from the AORN (Association of perioperative Registered Nurses) and the AACN (American Association of Critical-Care Nurses) working together with the leadership and corporate training company VitalSmarts. Their study The Silent Treatment. Why Safety Tools and Checklists Arent Enough to Save Lives is a revealing look at the current state of the culture of patient safety.
Based on a previous study done by these groups (Silence Kills. The Seven Crucial Conversations for Healthcare. 2005), the new study utilized two types of survey sent to members of AORN and AACN. One was a traditional survey, the other a story collector.
They honed in on three undiscussable issues: dangerous shortcuts, incompetence, and disrespect. They found that 4 out of 5 nurses participating in the study admitted they had concerns that one or more of these three undiscussables were potentially causing patient harm and that very often they did not discuss the issues with the party doing the undiscussable (who could be another nurse or a physician or other healthcare worker). In some cases they were more likely to bring the undiscussable to the attention of a supervisor. But even the nursing supervisors participating in the study admitted that they often did not confront the offending party or take appropriate action.
They did go a step further, however. Those nurses who did confront the offending parties provided examples of how they handled those difficult discussions. Those that did so successfully often used techniques that were face saving for the other party, yet effectively addressed the undiscussable issue.
Also, though the silence remains problematic, the authors do note that there has been progress since they did their previous survey in 2005. Compared to that study (Silence Kills: The Seven Crucial Conversations for Heatlh Care) participants were about 3 times more likely to speak directly to the person doing the offending activity in the current survey.
Both are studies that provide incredible insight and provide further evidence that our difficulties in moving the patient safety needle lie in our failure to change the culture of healthcare. You can download the "Silent Treatment" study and associated materials at the site below for free.
And, of course, physicians are little better in dealing with the same issues amongst their colleagues. A study last year (DesRoches 2010) showed many physicians fail to report or confront their colleagues who are either impaired or incompetent. A third of physicians who knew that a colleague was incompetent or impaired failed to report that physician. The most common reasons cited were belief that someone else would take care of reporting, belief that nothing would happen as a result of reporting, and fear of retribution.
The 2007 American College of Physician Executives (ACPE) Quality of Care Survey (Steiger 2007) revealed numerous issues considered by physician executives to be obstacles to quality of care or patient safety. But in many of the cases the perceived obstacles were failure of the system as a whole to deal with incompetent, impaired or disruptive physicians. Below are some of the quotes from respondents to that survey:
And, of course, the Joint Commissions Sentinel Event Alert #40 Behaviors That Undermine a Culture of Safety, issued in 2008, discusses the impact that disruptive behavior has on developing a culture of safety and makes numerous recommendations for each organization to identify such behaviors and deal with them appropriately.
Turning a blind eye or deaf ear to such problems just continues to make the working environment worse for all parties involved. Weve seen numerous occasions where staff had previously stepped forward to report such behaviors, only to be ignored or, worse yet, suffer retribution for their actions. So the organization as a whole needs to ensure a supportive environment is present so that staff do not feel uncomfortable in confronting such individuals or in addressing such threats to patient safety. You can have all the policies and procedures in the world but if your culture is not conducive to eliminating these hazards we will never move patient safety to that next level.
AACN/AORN/VitalSmarts. The Silent Treatment. Why Safety Tools and Checklists Arent Enough to Save Lives. 2011
American Association of Critical-Care Nurses (AACN) and VitalSmarts. Silence Kills. The Seven Crucial Conversations for Healthcare. 2005
DesRoches CM, Rao SR, Fromson JA, et al. Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues. JAMA 2010; 304(2): 187-193
Steiger B. Doctors Say Many Obstacles Block Paths to Patient Safety. The Physician Executive 2007; 6-14 May June 2007
ACPE. 2007 Quality of Care Survey
The Joint Commission. Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety. July 9, 2008
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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