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January 7, 2014
Lessons From the Asiana Flight 214 Crash
In our December 17, 2013 Patient Safety Tip of the Week “The Second Victim” we noted that we’d be looking at the many analogies between the tragic Asiana plane crash in San Francisco this past July and healthcare incidents. Our regular readers know we often use aviation analogies to help us understand root causes that underlie many of the adverse events we see in healthcare. The current NTSB investigation of the Asiana Flight 214 crash is loaded with examples that apply equally to aviation and healthcare, including training issues, learning curves, failure to heed alarms, failure to buck the authority gradient, cultural barriers, automation surprises, safety systems temporarily unavailable while under repair, and many more. Most of the important findings can be found in the Operations Group Chairman Factual Report and Interview Summaries, though important details can be found in the many documents included in the docket of the NTSB investigative hearing.
On July 6, 2013 Asiana Airlines Flight 214 crashed while landing at the airport in San Francisco (SFO), resulting in 3 deaths and over 200 injuries among the 307 passengers and crew aboard the aircraft. Basically, the crash occurred because the rate of speed for the aircraft was far below the recommended speed for landing. The result was that the rate of descent of the plane was too rapid and the plane hit a seawall just short of the runway, resulting in the back of the fuselage breaking off and the plane doing a cartwheel and then burning. It was actually miraculous that only 3 of the passengers died in this horrific crash.
The NTSB investigation, which should still be considered a work in progress at this point, did not uncover any significant mechanical, structural, or maintenance issues with the aircraft. Nor did it find any significant likely contribution from crew fatigue or distractions from personal computing devices, factors found to be contributory in many recent transportation accidents. And weather did not seem to be a contributory factor either.
But reading through the NTSB investigation documents and the media reports about the crash there are multiple root causes identified and most have analogies to incidents we see in healthcare:
The Learning Curve
The pilot flying the airplane at the time of the crash was an experienced pilot but was actually a trainee pilot on this particular plane. He had less than 45 hours of flight time on this model. In addition, he had not flown to the San Francisco airport since 2004. Note also that the supervising pilot was apparently also making his inaugural flight as a trainer.
The healthcare analogy is the experienced surgeon who is just beginning to perform procedures with a new technique. We saw complication rates soar when experienced surgeons first began doing laparoscopic cholecystectomies, bariatric surgery, robotic prostatectomies, etc.
Communication Issues/Lack of Hearback
Apparently there were several verbal warnings that the plane was descending too rapidly, beginning about a minute before the crash. The relief first officer, sitting in the jump seat behind the pilots gave three or four “sink rate” warnings in succession about 52 seconds before impact (Ahlers 2013).
When we meet with OR staff, nursing staff, medical residents, or others to discuss hierarchical issues we stress the importance of “hearback” and how they can “escalate their concerns”.
In the Asiana crash it is not clear whether hearback was utilized. The cockpit voice recorder did note the relief first officer called out “sink rate, sir” and the trainee pilot say “Yes, sir”. The first officer calling out the descent speed warning may have tried some form of escalation since, after 2 call outs in English, his third call out was in Korean (Wald 2013).
This is eerily similar to a previous airline crash that we often use in our sessions. In that previous crash the copilot can be heard multiple times on the cockpit voice recorder saying in a rather quiet calm manner “we’re running out of fuel”. Needless to say the plane ran out of fuel and crashed.
Hearback must indicate not just that something was heard but must rather convey that what was said was fully understood and that both parties have the same understanding. In healthcare we often have situations where jargon or abbreviations are used and all parties do not understand that nomenclature, leading to miscommunication and errors.
There are techniques that can be used to escalate concerns. One is the “Two-Challenge Rule”. In this the concern is first raised in a non-confrontational tone. If the concern is not acknowledged, you repeat the concern with more emphasis. If that second “challenge” is not acknowledged, you refer the issue to another person, eg. supervisor with authority to intervene or a trusted colleague
Many of you are more familiar with the CUSS acronym for escalating your concern tactfully:
C “I’m concerned and need clarification”
U “I am uncomfortable and don’t understand”
S “I’m seriously worried here”
S “Stop”
Unfortunately, some of the hierarchical and cultural issues described below have made it difficult for some to feel comfortable in raising issues. That is why it is critical that every organization emphasize the importance of speaking up and help them understand techniques to escalate their concerns.
The Hierarchical Issues
The pilot apparently harbored fears about landing safely while relying on manual controls and a visual approach but failed to tell anyone because he did not want to fail his training mission and embarrass himself.
While any of the three pilots could have broken off the approach it was noted that “is very hard” for “low-level people” which apparently included the pilot flying the plane who was being supervised by an instructor pilot (Wald 2013). That sentiment persisted despite the fact all had undergone cockpit resource management (CRM) training that encourages subordinates to speak up about safety concerns (Ahlers 2013).
We’ve said it time and time again – culture always trumps policy. How often have you found that your staff, even after they have undergone TeamSTEPPS™ training or CRM training, remain reluctant to speak up and buck the authority gradient even when they know something is wrong? It happens all the time. Especially when a hospital administration fails to back up those staff who had been willing to speak up and got admonished for doing so.
Failure to Heed Alarms
Aside from failure to heed the alarm about the too rapid descent (“sink rate”), there weren’t too many other alarms here. The audible alarm that signifies the aircraft is too low to the ground and the “stick shaker” that signifies an aerodynamic stall both did occur but the pilots were not able to react soon enough to increase speed and abort the landing.
But the one other display that should have caused alarm was the air speed indicator. The pilots had planned an approach speed of 137 knots but the actual speed had dropped to 103 knots just before impact. About 11 seconds before impact an electronic voice called out an alert about minimum speed. But the pilots, likely because they were under the misconception that the autothrottle was still engaged and would automatically increase their speed, failed to try to increase speed until just a few seconds before impact.
Failure to heed alarms is, of course, one of our “big three” root causes in almost every root cause analysis we do after a healthcare incident with serious adverse outcome (the other two being failure to buck the authority gradient and failed communications). Our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” discusses multiple aspects of alarms in healthcare and has links to our many prior columns on alarm issues.
The Other Cultural Issues
The pilot flying the airplane at the time of the landing also noted that he was temporarily blinded by a bright light on the runway, possibly a reflection of the sun. He was not wearing sunglasses because apparently that is considered a sign of disrespect or impoliteness in Korean culture (Wald 2013).
Today’s hospials have staffs that come from a variety of cultural backgrounds. It’s not enough to just be cognizant of potential language barriers that might impact communication. Other cultural “norms” may also create barriers to communication. We’ve often seen that regarding gender issues.
Lack of Standard Instrumentation/Design Issues
The plane was a Boeing 777. Even though the pilot was very experienced, he had less than 45 hours experience in that model. He described confusing some of the details of the automation system with that of the Airbus A320 on which he had more extensive experience (Wald 2013).
The pilots had left their “flight director” system, which includes the autopilot, partly on (Scott 2013). But on the Boeing 777 the system would not “wake up” from hold mode, meaning that the autothrottle system would not automatically speed up the plane if it fell below the target speed. Boeing said that its design uses the philosophy leaving the pilot in control of the airplane. On some other airplane models the autothrottle system would not be disabled and would automatically correct the speed.
We’ve often discussed lack of standardization as a risk factor for medical errors. One example we frequently point out is ventilators or alarm systems differing from one ICU to another in a hospital. When staff get “floated” from one ICU to the other they are often confronted with equipment that has dials and displays which differ considerably from those they have become accustomed to.
The Automation Issues/Overreliance on Technology
One of the major issues contributing to the crash was apparently overreliance on technology. The pilots apparently thought that the automatic throttle system was engaged, which should have increased engine thrust when the airplane speed fell below the recommended speed. However, that automatic throttle system was not engaged. Once the pilots recognized that their speed and altitude were too low and that the autothrottle had not automatically increased speed, they tried to initiate a “go round” (i.e. to abort the landing and fly around and try again) but it was too late.
It’s pretty clear that sometimes pilots don’t understand what mode the computer systems are in. The FAA has just released a comprehensive study on the overreliance of pilots on automation and loss of situational awareness due to automation surprises (FAA 2013).
Healthcare is no different. We often use computer systems in which multiple “modes” are available and we may not recognize which mode the system is operating in. Also, in all our discussions about alarm issues we note that erroneous assumptions are often made that an alarm will trigger when anything serious happens.
Why Hasn’t This Happened Before?
It has! Because of the design of this system you would anticipate that other pilots have likely experienced situations in which they thought the autothrottle was engaged when it was not. The ground school instructor interviewed by the NTSB stated that he provided specific training on this issue because he had personally experienced, in flight, an unexpected activation of HOLD mode and thus the failure of the autothrottle to re-engage (Operations Group Chairman Factual Report p. 8). He stated that he wanted to warn his students on this aspect of the B777 automation.
Healthcare organizations often fail to remember lessons learned from incidents within their own organizations. In our March 30, 2010 Patient Safety Tip of the Week “Publicly Released RCA’s: Everyone Learns from Them” we noted some cases where incidents occurred following identical prior incidents. Lessons learned and proposed solutions were either not implemented nor widely disseminated within the organization.
Airport Navigation System Out of Order
At the time of the crash in July the system at SFO that syncs with aircraft systems to help guide the landing was out of order. This was one of the factors that necessitated a visual/manual landing.
The pilot flying the airplane, who was highly experienced in a Boeing 747 but was transitioning to flying a Boeing 777, told the National Transportation Safety Board that he found it "very stressful, very difficult" to land without the glideslope indicator that helps pilots determine whether the plane is too high or too low during approach (Ahlers 2013).
Multiple pilots interviewed provided varying responses about their ability to perform visual approaches but the overall theme seems to have been that most were uncomfortable with visual approaches (Operations Group Chairman Factual Report p. 32-33). Though all were required to fly a visual approach in the simulator, some felt “this training was to fill in the square on the simulator check ride rather than to learn something”.
In healthcare we also sometimes attempt to function with equipment or systems we know are suboptimal. Sometimes we’ll see equipment failures midway through surgical procedures and find out that the particular piece of equipment had failed previously and never been fully repaired. That is one reason why the post-op debriefing is so important: that is where faulty equipment issues should always be discussed and referred to the person who may rectify the problem.
The Sterile Cockpit
Interestingly, compared to most of our previous columns on transportation accidents, there did not appear here to be any violations of the “sterile cockpit” rule. That rule requires that all unnecessary “chatter” cease during critical phases of the flight, such as takeoff and landing. On the cockpit voice recording the only possible extraneous bits of conversation were really about visual landmarks (eg. the Golden Gate Bridge, a golf course, etc.) and did not appear to be distracting in any way.
In healthcare that same “sterile cockpit” concept applies to all key situations where distractions must be avoided, such as during the surgical timeout or any verification scenario, the surgical “count”, and a host of other situations.
The Crash Response
The NTSB investigation looks not only at factors leading to the accident but also at “survival factors” and the response after the crash. While the overall response was credited with saving many lives, review of the response did identify opportunities for improvement.
Crew members did access instructions for evacuation and follow them. One emergency inflatable slide or raft deployed inappropriately and obstructed an exit and actually pinned a flight attendant. Fortunately another crew member recognized this and was able to deflate the slide enough for the flight attendant to escape.
But some images of the crash showed passengers ignoring official safety procedures and collecting their carry-on items before evacuating the aircraft (Thompson 2013).
Also, a Boeing evacuation engineer testified at the hearing that at least one and possibly two passengers who died did not have their seatbelts on (Braun 2013). One of the 3 fatalities was a girl who had already been found on the ground near the left wing of the plane but became covered in firefighting foam and got hit by emergency vehicle(s) on the runway.
An automated system designed to alert key managers at SFO failed during the period immediately following the crash (van Derbeken 2013). There were also questions about the communications between air traffic controllers in the tower, who could see some of the activity at the crash site, and emergency command center managers on the ground.
Healthcare organizations also need to look at their response after an untoward incident, analyzing not only the proximate and root causes of the incident but how people responded to it and what was done well and what might have been done better.
Do as I Say, Not as I Do
While many have focused on overreliance on technology as a key root cause in this and many other transportation accidents, we think there is another lesson here that is extremely important to healthcare. That is the disparity between what you say should be done and what is actually done.
There are a couple examples in this case. One was that both the Boeing (plane manufacturer) representative and the Asiana representatives stated their philosophies that the pilot should be in full control of the aircraft on landing. Yet the interviews with many Asiana pilots showed that landings using instruments and technology were the norm and that most pilots were extremely reluctant to do a “visual” or “manual” landing and that the simulation training actually paid only cursory attention to visual/manual landings.
Similarly, though all pilots underwent CRM training, which stresses the obligation of everyone to speak up when they see something wrong, the cultural norm in this airline was that they still deferred the important decisions to the “one in command”.
Healthcare organizations are also guilty of this. How many of you have sent your OR teams through TeamSTEPPS™ or CRM training yet failed to follow up, only to find after an incident that your OR culture had reverted back to its previous hierarchical morass? And how many hospitals flaunt their commitment to patient safety on their websites, yet relegate discussion about quality and patient safety at their Board meetings to the end of the agenda or fail to provide the resources needed for that commitment to safety? And how many turn a blind eye to bad behavior by that physician who brings the most “business” to the hospital (see our May 29, 2011 Patient Safety Tip of the Week “The Silent Treatment: A Dose of Reality”)?
It is always agonizing for victims of such transportation accidents and their families and for the second victims as well. But it would be even worse if we failed to learn from the events and apply those lessons learned in a constructive fashion.
See some of our previous columns that use aviation analogies for healthcare:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
August 7, 2007 “Role of Maintenance in Incidents”
August 28, 2007 “Lessons Learned from Transportation Accidents”
October 2, 2007 “Taking Off From the Wrong Runway”
May 19, 2009 “Learning from Tragedies”
May 26, 2009 “Learning from Tragedies. Part II”
January 2010 “Crew Resource Management Training Produces Sustained Results”
May 18, 2010 “Real Time Random Safety Audits”
April 5, 2011 “More Aviation Principles”
April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”
May 8, 2012 “Importance of Non-Technical Skills in Healthcare”
March 5, 2013 “Underutilized Safety Tools: The Observational Audit”
April 16, 2013 “Distracted While Texting”
May 2013 “BBC Horizon 2013: How to Avoid Mistakes in Surgery”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
References:
NTSB. Investigative Hearing. Crash of Asiana Flight 214, San Francisco, CA, 7/6/2013. NTSB 2013; December 2013
http://www.ntsb.gov/news/events/2013/asiana214_hearing/index.html
Operations Group Chairman Factual Report
http://dms.ntsb.gov/public%2F55000-55499%2F55433%2F543236.pdf
Operations Group Chairman Factual Report. Interview Summaries.
http://dms.ntsb.gov/public%2F55000-55499%2F55433%2F543238.pdf
Cockpit Voice Recorder (transcript)
http://dms.ntsb.gov/public%2F55000-55499%2F55433%2F544904.pdf
Ahlers MM. Pilot concerned about landing Asiana jet before crash. CNN.com December 11, 2013
http://www.samachar.com/NTSB-probes-fatal-Asiana-Flight-214-crash-nmltKyajccc.html
Wald ML. Nobody wanted to be rude: good manners helped doom Asiana flight 214. Sydney Morning Herald 2013; December 12, 2013
http://www.news.nom.co/nobody-wanted-to-be-rude-good-manners-7484199-news/
Scott A. Asiana crash pilots knew speed was low, hesitated. Reuters December 11, 2013
FAA. Operational Use of Flight Path Management Systems. FAA September 5, 2013
http://media.nbcbayarea.com/documents/FAA_Final_Report_Recommendations+11-22-13.pdf
Thompson C, Meng M, Did Asiana passengers ignore safety messages? CNN.com July 9, 2013
http://www.cnn.com/2013/07/09/travel/asiana-passenger-safety/index.html?iid=article_sidebar
Braun S, Mendoza M. Probe: Asiana pilot wasn't confident, assertive.
Associated Press/Denver Post December 11, 2013
http://www.denverpost.com/breakingnews/ci_24700519/ntsb-review-asiana-crash-at-hearing-wednesday
Van Derbeken J. SFO reveals missteps after Asiana crash. SFGate.com November 21, 2013
http://www.sfgate.com/bayarea/article/SFO-reveals-missteps-after-Asiana-crash-4996962.php
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January 14, 2014
Diagnostic Error: Salient Distracting Features
Salient distracting features (SDF’s) are one mechanism by which cognitive biases may enter our diagnostic reasoning and potentially lead to diagnostic errors. These are features in a patient’s history that may be strongly associated with a disease or condition and thus catch the attention of the clinician. Particularly when reasoning in a pattern recognition mode, the clinician may be so distracted by the feature that a cognitive bias is introduced. When that SDF is not actually relevant to the patient’s case, a diagnostic error may ensue.
In our May 15, 2012 Patient Safety Tip of the Week “Diagnostic Error Chapter 3” we discussed a study from the Netherlands (Mamede 2012) looked at diagnostic reasoning in medical students and internal medicine residents. They had previously noted that salient distracting features are a major contributor to diagnostic errors, particularly when in the non-analytic reasoning mode. They showed that reflective reasoning led to significantly more correct diagnoses. Interestingly, students did not benefit from reflective reasoning. The implication is that certain salient features may attract a physician’s attention and misdirect the diagnostic reasoning process. Reflective reasoning may help overcome the influence of these distracting features.
Now the same group (Mamede 2013) has further studied the role of salient distracting features in internal medicine residents analyzing simulated cases based upon actual patients. They asked the residents to diagnose 12 clinical cases (6 simple, 6 complex) in three different formats. Some had an SDF inserted near the beginning of the case, some near the end of the case, and some with no SDF. When an SDF was presented early in a complex case there were 58% fewer accurate diagnoses than when no SDF was present. And the accuracy of diagnoses was about 50% fewer when an SDF was presented at the beginning rather than end of a case. The presence of an SDF also increased the amount of times spent making a diagnosis.
An example of a salient distracting feature in the above studies was noting early in the case that the patient had a positive PPD and family history of remote treatment for TB.
But I can provide a great personal example where salient distracting features led me astray in diagnosing myself! Several years ago I began to limp, primarily due to weakness in my left leg. It was pretty much painless except for some low-level aching in the mid-thigh region. The thigh was visibly smaller on the left than the right (measuring 2 cm. smaller in circumference). My father had died from ALS (amyotrophic lateral sclerosis). Being a neurologist, my first thoughts were, of course, that I had ALS (as many as 10% of ALS cases may have a familial component). So I went to one of my trusted colleagues for an EMG. I even informed him which muscle groups he’d likely see fasciculations, since by now I was looking for any other signs that would support a diagnosis of ALS (and almost everyone gets fasciculations from time to time that are benign in nature). How relieved I was when the EMG was normal. But that still left the limp unexplained. So we scheduled some hip X-rays. Because what little pain I had was in mid-thigh and because something in mid-thigh seemed to suddenly “catch” sometimes while walking, I insisted we also get X-rays of the thigh as well. The X-rays did show fairly significant hip arthritis on both sides. The thigh X-ray showed about a 6-inch ossification of a muscle and tendon in mid-thigh. I suspected that was likely due to a very old lacrosse injury. But it was also right where my main symptoms were located. I did at that time get my left hip injected (with both a local anesthetic and a steroid) as a diagnostic test. It produced no significant improvement. Six weeks of physical therapy led to only slight improvement. I was convinced my problem was fully related to the myositis ossificans. My limp got progressively worse. I used to walk/jog almost 8 miles a day. Now I could only walk about 2 miles a day with difficulty and could no longer jog at all. If I stood with all my weight on just the left leg, I would hear a “sproing” sound, further increasing my concern that the symptoms were related to the myositis ossificans. The literature paints a very pessimistic picture for treatment of myositis ossificans. Surgery is not likely to be helpful. There are a few case reports of symptom improvement after extracorporal shock wave therapy. Local injections with iontophoresis have also been reported to improve symptoms in some cases. I finally tracked down an orthopedic surgeon who had some experience with extracorporeal shock wave therapy. But when I saw him he took one look and said “this is all coming from that hip”. Even though I obviously understand the concept of referred pain, I still remained skeptical since I lacked the more typical hip or groin pain seen with hip arthritis. I could still kayak and I slogged through a trip-of-a-lifetime to Alaska where I was able to go on most hikes because I could use hiking poles. But I finally acquiesced to have a left total hip replacement.
My surgeon was great. The surgery went smoothly and I was out of the hospital in less than 24 hours! My thigh pain disappeared almost immediately. My rehab consisted of daily exercises at home. (I recall the “old days” when a total hip replacement patient stayed in the hospital for a couple weeks!). My limp is gone. By six weeks post-op I was cross-country skiing and by eight weeks I was downhill skiing!
My self-misdiagnosis obviously shows multiple types of cognitive bias that we commonly see in diagnostic error. Anchoring, framing, early closure and confirmation bias were all clearly operative. But very significant were the two salient distracting features (the family history of ALS and the muscle ossification on X-ray). Fortunately, my diagnostic error was not on one of my patients. And, fortunately, it didn’t lead to any significant harm. But it did have a significant impact on my lifestyle that could have been avoided if I had gone ahead with the hip replacement a couple years earlier!
In the diagnostic process we often need to step back. Most often when we do that we ask ourselves “what might I be missing?”. But just as important is to ask “what might I be giving too much weight to?” or “would I be thinking differently if {blank} was not present?”.
Some of our prior columns on diagnostic error:
References:
Mamede S, Splinter TAW, van Gog T, et al. Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. BMJ Qual Saf 2012; 21:295-300 doi:10.1136/bmjqs-2011-000518
http://qualitysafety.bmj.com/content/21/4/295.abstract
Mamede S, van Gog T, van den Berge K, et al. Why Do Doctors Make Mistakes? A Study of the Role of Salient Distracting Clinical Features. Academic Medicine., POST AUTHOR CORRECTIONS, 25 November 2013
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January 21, 2014
The PICC Myth
In a casual conversation we recently heard about difficulty getting a central line for a patient the question “Why didn’t they just put in a PICC?” was asked. Unfortunately, that question is asked too frequently and too easily in hospitals across the country. RN’s place about 70% of the nearly 3 million PICCs that are inserted annually in the United States (The Joint Commission 2012). Particularly since most hospitals have developed PICC teams led by nurses and radiologists, it has become all too easy for physicians to order a PICC line without thinking much about it.
The potential complications of PICC (peripherally inserted central catheter) lines are at least as frequent as and probably more frequent than those from more traditional central lines. We used to kid about our ability to identify the service line of a patient by the location of their central line (if the patient had a subclavian line they were on the surgical service, if they had an jugular line they were on the medicine service). True, the most feared complications of those central line insertions (pneumothorax for the subclavian line, carotid arterial puncture for the jugular line) are not seen with PICC insertions but a host of serious potential complications are associated with PICC’s.
Chopra and colleagues (Chopra 2013a) did a systematic review and meta-analysis comparing the risk of venous thromboembolism associated with PICC’s versus that associated with other central venous catheters (CVC’s). PICCs were associated with a more than two-fold increased risk of deep vein thrombosis (OR 2.55) but not pulmonary embolism. PICC-related deep vein thrombosis was highest in patients who were critically ill and those with cancer, indicating the importance of patient-related risk factors as well.
In a study utilizing venous duplex imaging of the upper extremities Liem et al (Liem 2012) found an overall low incidence of symptomatic PICC-associated UE DVT but given the number of PICCs placed each year, they account for up to 35% of all diagnosed UE DVTs. Larger-diameter PICCs and malignancy were factors found to increase the risk for DVT.
Another study (Marnejon 2012) found trauma, renal failure, left-sided catheters, basilic placement, TPN, and infusion with antibiotics, specifically vancomycin, were significant risk factors for upper extremity venous thrombosis associated with PICC insertion.
Most healthcare professionals have probably assumed that the risk of CLABSI’s (central line-associated bloodstream infections) would be lower with PICC lines compared to conventional central lines. This appears to be the case for outpatients but is probably not so for inpatients. In another systematic review and meta-analysis Chopra and colleagues (Chopra 2013b) found 23 studies comparing CLABSI rates in patients with CVC’s vs. PICC’s. For outpatients rates of CLABSI were much lower in those with PICC’s (RR 0.22). For hospitalized patients there was also a trend toward fewer CLABSI’s in those with PICC’s but when the rates were adjusted per catheter day, there was no significant difference in CLABSI rate between the CVC and PICC groups.
But the Chopra review reveals a couple problems. First, there was only a single small randomized controlled study. And few studies included patient- and device-related data. It is pretty clear that there are risk factors for CLABSI that are patient-related or device-related (eg. number of lumens, size of catheter, etc.). And most did not indicate what preventive measures were used for either CVC’s or PICC’s.
So we really don’t know for sure whether PICC’s have a lower or equivalent rate for CLABSI’s. But rates of CLABSI in inpatients with PICC’s are likely substantial. Anecdotally, we also tend to see far less adherence to well-known best practices for CLABSI prevention in patients not in ICU’s and many such patients with PICC’s are not in ICU’s.
In a prospective study of non-ICU patients (Al Raiy 2010) with active surveillance and intervention to remove unnecessary or high-risk lines, CVC’s and PICC’s had similar rates of CLABSI’s. The median time to development of infection was significantly longer in the patients with a PICC (23 vs 13 days), a temporal pattern often noted by others.
One of the most important interventions in prevention of CLABSI’s (or, for that matter, infection of any indwelling device) is asking on a daily basis whether the catheter is still necessary. With PICC’s we often forget to do that, particularly when the patient is not in the ICU. Tejedor and colleagues (Tejedor 2012) looked at how often central venous catheters and PICC lines were retained when not needed ("idle days") on non-ICU wards. They found that significant proportions of ward central line days were unjustified. Patients with PICCs had more days in which the only justification for the CVC was intravenous administration of antimicrobial agents. They suggest that reducing "idle CVC-days" and facilitating the appropriate use of peripheral IV’s may reduce central line days and CLABSI risk.
But other complications may be seen with PICC’s as well. One study (Pikwer 2012) found that catheter tip malpositioning, thrombophlebitis, and catheter dysfunction were more common with PICC’s than CVC’s. The two catheter types did not differ with respect to catheter-related infection rates.
Some studies have been done on more specific patient populations. In a retrospective review of neurological intensive care patients (Wilson 2013) there was a statistically significant difference in catheter-related large vein thrombosis with PICC’s compared to CVC’s, with no difference in CLABSI or line insertion-related complications. A study in oncology patients (Johansson 2013) concluded that although PICCs are frequently used in oncology, scientific evidence supporting any advantage or disadvantage of PICC when comparing PICC with traditional central venous lines is limited, apart from a tendency towards increased risk for DVT and a decreased risk for catheter occlusion with PICC.
Device-related factors are also important. PICC diameter may pose the most modifiable risk for PICC-associated DVT and the risks increase as the number of catheter lumens increases. Evans et al. (Evans 2013) found a significant increase in the use of single-lumen PICCs in addition to the institutional adoption of smaller 5F triple-lumen PICCs was associated with a significant decrease in the rate of PICC-associated DVT.
So it is fairly clear that PICC’s may be associated with a variety of complications. So any decision about use of PICC’s must balance the potential benefits against the potential risks. There’s little question that the benefits outweigh the risks in many cases. PICC’s allow many patients to receive long-term antibiotics or chemotherapy at home rather than requiring inpatient hospital stays.
The benefit vs. risk decision is more difficult for inpatients. PICC lines have even made one of the Choosing Wisely® lists of things physicians should question (Society of General Internal Medicine Choosing Wisely® list). Specifically, the item is “Don’t place, or leave in place, peripherally inserted central catheters for patient or provider convenience”. They cite the potential complications noted above and the study (Tejedor 2012) that PICC’s were often associated with “idle days” or days when the lines were not used for a relevant indication. The Choosing Wisely® list also notes patient demand as another factor that may drive increased use of PICC lines, as noted in the survey data below (Chopra 2013c).
One problem related to PICC’s is a relative lack of evidence-based indications for their use (Butterfield 2013). Most indications have been based on practical considerations or expert consensus, both of which we know commonly lead to overuse. We, of course, encountered the same issue years ago when we first began addressing urinary catheters. Only once we defined appropriate indications for urinary catheters using evidence were we able to significantly reduce the overall use of urinary catheters, leading to subsequent reductions in CAUTI’s. The article by Butterfield indicates that Chopra and others are planning a conference to develop evidence-based guidelines for PICC use.
A survey of hospitalists in Michigan (Chopra 2013c) identified numerous gaps in understanding and utilization of PICC’s, with a substantial percentage of hospitalists suspecting that 10-25% of PICC’s at their facilities might be inappropriately placed or avoidable. Most hospitalists did not themselves regularly examine the PICC’s for evidence of external problems and a majority noted that, at least once, they had forgotten the patient had a PICC. Many noted placement of PICC’s for venous access as opposed to a specific indication (like total parenteral nutrition or long-term antibiotic administration) and 82% reported having cared for a patient who specifically requested a PICC.
Wojnar and Beaman (Wojnar 2013) reviewed a hospital’s inpatient use of PICC’s to determine whether PICC’s were appropriately indicated. They note that CDC (O'Grady 2011) recommends PICC’s for patients with an intended duration of IV therapy >6 days. The type of intravenous preparation is important. Indications for administration via PICC include vesicants (blistering agents, eg. chemotherapy), irritants, preparations with pH <5 or >9 or osmolarity > 600. But they also discuss patient-related factors that may be important in the decision to use PICC’s. These include factors such as skin condition in elderly patients, morbid obesity, severe dehydration, complicated medical diagnoses, poor physical condition, abnormal coagulation status, and others.
So hopefully the next time you hear the question “Why don’t they just put in a PICC?” you’ll actually take time to weigh the pros and cons before answering. And hopefully you will apply the same degree of rigor to daily monitoring of the PICC and the need for its continuation that you would apply if the patient were in an ICU.
References:
The Joint Commission. Preventing Central Line–Associated Bloodstream Infections. A Global Challenge, A Global Perspective. The Joint Commission 2012
http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf
Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. The Lancet 2013; 382(9889): 311-325
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960592-9/fulltext
Liem TK, Yanit KE, Moseley SE, et al. Peripherally inserted central catheter usage patterns and associated symptomatic upper extremity venous thrombosis. J Vasc Surg 2012; 55(3): 761-767
http://www.jvascsurg.org/article/S0741-5214%2811%2902321-4/abstract
Marnejon T, Angelo D, Abu Abdou A, Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters. J Vasc Access 2012; 13(2): 231-238
Chopra V, O'Horo JC, Rogers MA, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013; 34(9): 908-918
Al Raiy B, Fakih MG, Bryan-Nomides N, et al. Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters. Am J Infect Control 2010; 38(2): 149-153
http://www.ajicjournal.org/article/S0196-6553%2809%2900745-7/abstract
Tejedor SC, Tong D, Stein J, et al. Temporary central venous catheter utilization patterns in a large tertiary care center: Tracking the "Idle central venous catheter". Infection Control and Hospital Epidemiology 2012; 33(1): 50-57
Pikwer A, Akeson J, Lindgren S. Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia 2012; 67(1): 65-71
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06911.x/abstract
Wilson TJ, Stetler WR, Fletcher JJ. Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherally inserted central venous lines in the neurological intensive care unit. Clinical Neurology and Neurosurgery 2013; 115(7): 879-882
http://www.clineu-journal.com/article/S0303-8467%2812%2900450-7/abstract
Johansson E, Hammarskjöld F, Lundberg D, Arnlind MH. Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature. Acta Oncol. 2013; 52(5): 886-892
http://www.ncbi.nlm.nih.gov/pubmed/23472835
Evans RS, Sharp JH, Linford LH, et al. Reduction of peripherally inserted central catheter-associated DVT. Chest 2013; 143(3): 627-633
http://journal.publications.chestnet.org/article.aspx?articleid=1654281
Choosing Wisely®. Society of General Internal Medicine list: Five Things Physicians and Patients Should Question. Choosing Wisely® 2014
http://www.choosingwisely.org/doctor-patient-lists/society-of-general-internal-medicine/
Chopra V, Kuhn LK, Coffey C, et al. Hospitalist Experiences, Practice, Opinions and Knowledge Regarding Peripherally Inserted Central Catheters: A Michigan Survey. J Hosp Med 2013; 8(11): 635–638
http://onlinelibrary.wiley.com/doi/10.1002/jhm.2095/abstract
Butterfield S. Be picky about PICCs. Research reveals complication rates, common errors, high-risk patient groups. ACP Hospitalist 2013; September 2013
http://www.acphospitalist.org/archives/2013/09/coverstory.htm
Wojnar DG, Beaman ML. Peripherally Inserted Central Catheter: Compliance with Evidence-Based Indications for Insertion in an Inpatient Setting. Journal of Infusion Nursing 2013; 36(4): 291-296
O'Grady NP, Alexander M, Burns LA, et al. 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) 2011
http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html
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January 28, 2014
Is Polypharmacy Always Bad?
Is polypharmacy always bad? That’s a question that a group of researchers in the UK have recently challenged (Payne 2014).
We often consider polypharmacy to be a measure of poor quality. There are clearly reasons why increasing numbers of drugs taken may lead to adverse events. We know that the likelihood of drug-drug interactions increases with the number of medications taken. Also side effects of medications may be additive. For example, taking multiple drugs that have anticholinergic side effects may result in clinical anticholinergic symptoms that would not have occurred with only one drug. Or drugs that may be associated with orthostatic hypotension may have additive effects to make that orthostatic drop in blood pressure symptomatic. And multiple studies have demonstrated that polypharmacy is a risk for unplanned hospitalizations.
But Payne and colleagues (Payne 2014) have pointed out that most previous studies linking polypharmacy to unplanned hospitalizations have had certain flaws. First, they may have dichotomized variables (i.e. they used “more than x medications” to define polypharmacy vs. no polypharmacy). Second, they often did not take into context the reasons the patients were taking multiple medications or the number of comorbidities. And many were done on select patient populations (eg. only the elderly or nursing home residents).
So they performed a retrospective analysis of patients in Scotland to further study the relationship between medications and hospitalizations. Though it was a retrospective analysis rather than a randomized controlled trial, the study utilized a comprehensive data set on over 180,000 patients from 40 family practices that were representative of the population as a whole, had close to 100% capture of medications prescribed, and linked to a database that stored hospital admission data. Also, rather than dichotomizing the polypharmacy variable, they split the medication variable into a continuum of ranges (eg. none, 1-3, 4-6, 7-9, and 10 or more medications).
Their findings are interesting. Yes, they confirmed that there is a strong correlation overall between the number of drugs taken and the risk of unplanned hospital admission. Patients taking 4-6 medications were more than twice as likely to have an unplanned admission than those taking 1-3 medications. And those taking 10 or more medications were 6 times more likely to be admitted than those taking 1-3 medications.
But when they factored in comorbidities they found that the strength of the association between number of medications and unplanned admissions was greatly reduced as the number of comorbidities increased. In fact, for the patients with the most comorbidities (6 or more conditions) there was no difference in the risk of unplanned admission between those taking 4-6 medications vs. those taking 1-3 medications. Even for those taking 10 or more medications the risk was only moderately increased (OR 1.5).
They explain their results by noting that many studies on polypharmacy have ignored one very important factor that seems counterintuitive: underprescribing! That is, patients on multiple medications may not be taking a medication that is very important for at least one of their underlying conditions. Of course, it may not be truly underprescribing. Rather it may reflect poor compliance, a phenomenon we tend to see increase with the number of medications prescribed. In their study some further data supported their assertion that underprescribing may play a role. Those patients with 6 or more comorbidities who were receiving no medications were more likely to be admitted than those receiving 1-3 medications.
It certainly makes sense. If your patient has CHF, CAD, diabetes, and several other conditions but is not taking those medications shown to reduce hospitalizations and complications from those diseases, they are more likely to be admitted.
The authors therefore caution against the use of “polypharmacy” per se as a quality indicator because it may be misleading. They suggest that measures of inappropriate prescribing (eg. Beers’ list, STOPP list) are likely to be better quality metrics than using total number of medications. In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?” we noted the STOPP criteria identified potentially avoidable ADE’s impacting on hospitalization over twice as often as did Beers’ criteria.
We’ve done multiple columns on Beers’ list, the STOPP list, and inappropriate prescribing in the elderly (see the list at the end of today’s column). We are also strong advocates of regular reviews of a patient’s medications (medication therapy management or MTM). See our May 7, 2013 Patient Safety Tip of the Week “Drug Errors in the Home” for details on MTM. We’ve mentioned multiple times that when we do such reviews on high-risk patients we almost always come away with medication lists that are 1-2 medications shorter (because of therapeutic duplication or medications no longer needed). But the work of Payne and colleagues would suggest we need to add another column to our MTM sheets – one for evidence-based medications that are missing for a condition the patient has!
In our hospitals we’ve already added such a column to our discharge checklists and this has helped hospitals improve their compliance with quality metrics for a variety of P4P programs. But we probably have not kept up to date on our similar MTM lists on the outpatient side.
So is polypharmacy always bad? No, what we really need to strive for is “eupharmacy”.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Patient Safety Tips of the Week:
What’s New in the Patient Safety World columns:
References:
Payne RA, Abel GA, Avery AJ, et al. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. British Journal of Clinical Pharmacology 2014; 15 January 2014
http://onlinelibrary.wiley.com/doi/10.1111/bcp.12292/pdf
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February 4, 2014
But What If the Battery Runs Low?
It’s a question we often find ourselves asking during FMEA’s (Failure Mode and Effects Analyses) or RCA’s (root cause analyses). We put so many redundancies into our systems to try to ensure that nothing can go wrong. Then we get a bad outcome because we neglected to remember a simple battery system might go dead.
You just revised your alarm safety policies and procedures as you prepare for the new Joint Commission NPSG on alarm management and safety. As part of your project you implemented middleware that transmits the alarm alerts to your nurses (or others) via their cell phone or pager. A patient event triggers an alarm that is sent to the primary nurse expected to respond. Unfortunately, the battery in her cell phone has failed and she never receives the alert. Fortunately, the escalation procedure you built into your system sends the alert to a secondary nurse who responds to the patient and no harm comes to the patient.
You implemented a “panic button” system to protect your behavioral health workers from assaults by patients on your locked behavioral health unit. The worker is in a situation where she fears potential harm from a patient and presses the panic button. However, the battery in the panic button is dead. Fortunately, other staff were within audible range of her shouts for help and responded before she was assaulted.
A patient is being monitored by remote telemetry (CDPH 2014). The battery charge on the 9-volt battery on the remote unit is running low. The audible alarms for low battery status had been turned off and the only ones working were the visual ones. A low battery warning appears as a yellow alarm on the screen. It later turns red but once the battery is dead no tracing at all appears on the remote monitor screen. The nurse who was manning the remote monitoring station (because no monitor tech was available) has multiple other distractions and does not see the yellow or red low battery alerts. The patient has a fatal event not picked up by monitoring.
A patient is on a portable ventilator in the ED while awaiting a bed in the ICU (see our April 2, 2007 Patient Safety Tip of the Week “More Alarm Issues”). The portable ventilator has a dual power supply (AC from wall sockets and a battery on the unit). Unbeknownst to staff the circuit breaker for the wall socket into which the AC cord was connected had tripped and the ventilator was running on battery power. When the battery charge ran out several hours later the patient had a cardiopulmonary arrest.
You have an alarm that responds to the temperature in a refrigerator dropping below a set value to protect against loss of the medical products inside. You took great care to make sure the thermometer was not on the same electrical supply as the refrigerator. However, the battery on the thermometer had not been checked recently and had no charge when the refrigerator actually lost power. All the medical products in the refrigerator are lost.
A power failure (Hazlett 2013) at a hospital occurs. The emergency generator comes on after 5-6 seconds but the memory battery does not back up the temperature setting on an infant isolette temperature setting. The temperature setting reverts to the manufacturer default setting and the isolette becomes too hot for the baby.
An infusion pump (MHRA 2005) was used when transporting a patient between hospitals. Staff checked that the display on the pump said that the battery would last 4 hours (longer than the expected journey time), but the pump batteries expired after 90 minutes. On investigation it was found that the manufacturer’s instructions stated that the battery indication was not reliable until 5 minutes after switch on. This had not been noted in training.
These are just a few examples of cases where batteries running low impacted or had the potential to impact patient outcomes. The problem is prevalent enough and significant enough that the FDA convened a special 2-day public workshop last year to begin to address the issue (FDA 2013a).
A survey of providers done before the conference in 2013 (FDA 2013b, Hazlett 2013) identified multiple devices that are battery-powered: a whole host of physiological monitors, automated blood pressure recording devices, telemetry packs and boxes, electrocardiograms, pulse oximeters, thermometers, glucose meters, infusion pumps (large volume infusion pumps, syringe pumps, patient-controlled analgesia pumps, etc.), portable computer stations (eg. computers on wheels), sequential compression devices, patient lifts, ventilators, defibrillators, CPAP/BiPAP machines, patient beds, and many others.
The following specific problems were noted in the survey: failure to plug-in device when not in use, overcharging, undercharging, inaccessible plugs/outlets, battery leakage, battery swelling, confusion with on/off button on pump, loose connections, and incorrect battery replacement by staff.
But most hospitals do not have an organized centralized program for battery maintenance. In the survey above most hospitals noted that nursing staff is responsible for charging battery-powered medical devices on the units where they are used but that staff often forget to plug in the devices or outlets are not available when needed. They note this is especially problematic when portable devices are moved from one unit to another. Often batteries are undercharged. An example given is a device charged for only 15 minutes when a full charge would require several hours. They also note that not all devices have low battery alerts. In many, such as pulse oximeters, error codes just display when the battery is low. And don’t forget that some batteries have “memory” and if frequently charged will only charge to the last level, which may be low.
But overcharging can also be a problem. Overcharged batteries can swell, overheat, explode or cause fires.
Sometimes design issues are the problem. In the portable ventilator case note earlier there was a light that indicated whether the ventilator was on AC current or battery but that indicator light was on the back of the unit where it was not readily visible.
The issues noted related to portable devices that are used during patient transports are of particular interest. We’ve often talked about items to include in your “Ticket to Ride” communication tools that should be used during patient transports (see our Patient Safety Tips of the Week for April 8, 2008 “Oxygen as a Medication” and November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”). But we’ve never included a specific area to comment about battery life issues for portable equipment. You learn something new every day!
Another problem is that the instructional manuals for the device or batteries are often not available at the point of care where the information is needed.
There’s also often poor communication between staff purchasing batteries and those using them so that problematic batteries simply get reordered over and over.
Issues related to storage, maintenance, sterilization, and proper disposal of batteries are beyond the scope of today’s column but are important considerations for your overall battery management initiative. Information on such issues is available at other sites (MHRA 2005).
Battery maintenance, replacement, service calls, disposal, etc. can also be quite expensive. So your CFO should have an interest in getting your battery management program in order.
Does your facility have a battery management policy and procedure? We’ll bet not. So while you are doing your alarm inventory as part of your activities to meet NPSG 06.01.01 (see our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” and our What’s New in the Patient Safety World columns for February 2013 “Joint Commission Proposes New 2014 National Patient Safety Goal”, May 2013 “Joint Commission Sentinel Event Alert: Alarm Safety” and August 2013 “Joint Commission Formalizes 2014 NPSG on Alarm Management”) you should be doing a related inventory of all your systems that utilize batteries. The sorts of questions you should be asking are:
And if you are using cell phones or pagers for alerting staff to various alarms, consider doing a FMEA (failure mode and effects analysis) and ask not only what would happen if the primary responder’s battery is low but also what would happen if more than one responders’ battery is low.
When you do your inservices and staff education on battery-related issues don’t forget to include some of the examples at the beginning of today’s article. A session titled “Battery Management Issues” is guaranteed to be a “snoozer”. So you need to spice up that talk by showing them some real life cases with unfortunate outcomes to get and keep their attention. Remember – “stories, not statistics”.
Lastly, don’t forget that there are battery-related issues with some of the equipment your patients may be using at home. Don’t forget to discuss these as part of your discharge process.
Batteries may sound like a mundane issue. But you can see from today’s column that battery-related issues are real patient safety concerns. Make sure you develop an organizational battery management program in conjunction with your alarm safety and management program.
References:
CDPH (California Department of Public Health). Complaint CA00221802. Accessed 2/2/14
Hazlett A. Overview of MedSun Survey. FDA Public Workshop - Battery-Powered Medical Devices Workshop: Challenges and Opportunities, July 30-31, 2013
http://www.fda.gov/downloads/MedicalDevices/NewsEvents/WorkshopsConferences/UCM364541.pdf
MHRA (Medicines and Healthcare products Regulatory Agency) UK. Device Bulletin. Guidance on the safe and effective use of batteries and chargers for medical devices. MHRA October 2005
http://www.mhra.gov.uk/home/groups/dts-pcc/documents/publication/con2022471.pdf
FDA. Public Workshop - Battery-Powered Medical Devices Workshop: Challenges and Opportunities, July 30-31, 2013
http://www.fda.gov/MedicalDevices/NewsEvents/WorkshopsConferences/ucm355183.htm#webcast
FDA. Discussions with Healthcare Providers. Batteries in Medical Devices: Small Sample Survey Summary. Survey Topic: Batteries in Medical Devices - Summary of Responses. Year Conducted: 2013
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/news/newsletter.cfm?news=84#9
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February 11, 2014
Another Perioperative Handoff Tool: SWITCH
Handoffs have been the topic of some of our most popular columns (see the list of all our handoff-related columns at the end of today’s column). Handoffs, of course, are key links in the patient safety continuum and faulty handoffs are a major root cause in many untoward incidents in any industry, not just healthcare. Doing the handoff in a setting that promotes communication and allows the recipient ample time to ask questions and get clarifications is critical. But having a standardized format is also very important. Our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” discussed several handoff tools and corresponding mnemonics which may be very helpful in your handoffs. The key message is that you need to implement tools that address the needs of each particular type of handoff that occurs in your organization. Though using a structured communication format or tool is important, the exact tool or format needed will vary by the nature of the handoff so “one size does not fit all”.
In the perioperative setting, the nature of handoffs is often very different from the resident-to-resident or nurse-to-nurse handoffs done on a medical unit. We highlighted the AORN toolkit in our December 2011 What’s New in the Patient Safety World column “AORN Perioperative Handoff Toolkit” and several abstracts presented at the 2011 American Society of Anesthesiologists annual meeting dealt with perioperative handoffs/handovers. And in our March 2012 What’s New in the Patient Safety World column “More on Perioperative Handoffs” we highlighted a multidisciplinary and interdisciplinary handoff process developed at Hopkins designed for transfers of patients from OR to PACU or PACU to ICU, etc. (Petrovic 2012a, Petrovic 2012b).
But even within the perioperative area there are a variety of handoffs that occur between different personnel and these need to be customized for the context of those interactions. A recent article in the AORN Journal (Johnson 2013) described the development and implementation of yet another standardized format for perioperative handoffs: SWITCH. They describe a quality improvement project at Provident St. Vincent Medical Center in Portland, Oregon that began with analysis of barriers to effective communication in the perioperative setting. One of their findings was that a standardized tool was needed for their handoffs and that it needed to be tailored to the needs of those involved in the handoffs. So they developed their own tool that goes by the acronym “SWITCH” which stands for:
S Surgical procedure
W Wet (i.e. fluids)
I Instruments
T Tissue (eg. specimen)
C Counts
H Have you any questions?
Their initial implementation was aimed toward handoffs between RN circulators or between scrub persons. The article provides a sample of the tool in checklist format with boxes for the various subitems under each category. For example, under W (for wet) they include IV fluids, medications, blood loss and blood products available, urine output, drains, etc.
They nicely describe the rollout and implementation of the SWITCH program. They used multiple venues for inservicing and learning and obtaining feedback as the tool developed. Laminated forms were available in several locations, including a pocket card that could be worn behind staff nametags. The article provides examples of what a handoff would sound like between two RN circulators or between two scrub persons.
Based on positive feedback on the SWITCH tool they recognized the need for similar tools to be used by OR front desk/scheduling nurses, or by OR charge nurses. So they developed handoff tools for these, again using the SWITCH acronym but with different items for the specific handoff. For example, for the front desk handoff:
S Staff issues (eg. overtime, sick call)
W What still needs to be done (eg. rooms running, those needing setup, etc.)
I Items (eg. loaned items, items needing repair, etc.)
T Time (eg. time available, gaps in schedule)
C Cases (eg. cancellations, add-ons, etc.)
H Have you any questions?
And then the anesthesia department got into the mix, modifying the tool for it’s own needs. The article provides an example of the much more complicated tool developed for the anesthesia handoff, still using the SWITCH acronym.
While the authors don’t report any metrics on actual use of the tool or impact on patient outcomes, they did find that very high percentages of staff surveyed felt that the tool was important and easy to use. The fact that so many other providers wanted their own version of the tool is a further testament to its utility.
Read the Johnson article and see the sample checklist versions of the SWITCH tools. You will find them very helpful. This once again emphasizes a point we’ve made over and over: while a standardized format for handoffs is very important, the format must be customized for the nature of the handoff and its participants and “one size does not fit all”.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
References:
Petrovic MA, Martinez EA, Aboumatar H. Implementing a Perioperative Handoff Tool to Improve Postprocedural Patient Transfers. Joint Commission Journal on Quality and Patient Safety 2012; 38(3): 135-4AP(-130)
http://www.ingentaconnect.com/content/jcaho/jcjqs/2012/00000038/00000003/art00006
Petrovic MA, Aboumatar H , Baumgartner WA. Pilot Implementation of a Perioperative Protocol to Guide Operating Room–to–Intensive Care Unit Patient Handoffs. J Cardiothorac Vasc Anesth 2012; 26(1): 11-16
http://www.jcvaonline.com/article/S1053-0770%2811%2900528-3/abstract
Johnson F, Logsdon P, Fournier K, Fisher S. SWITCH for Safety: Perioperative Hand-off Tools. AORN Journal 2013; 98(5): 494-507
http://www.aornjournal.org/article/S0001-2092%2813%2900947-2/abstract
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February 18, 2014
Nudged, But Who Nudged Who?
A new study “Nudging Guideline-Concordant Antibiotic Prescribing. A Randomized Clinical Trial” (Meeker 2014) showed that a simple, inexpensive intervention resulted in a 19.7% absolute reduction of inappropriate prescribing of antibiotics for acute respiratory infections. The intervention was posting in clinic sites visible to patients a poster-sized letter signed by the clinician committing to not prescribe antibiotics inappropriately. The letter explained the reasons for not prescribing antibiotics in many cases and was displayed in both English and Spanish at the eighth-grade reading level. A photograph and signature of the clinician appeared on the poster.
Baseline rates of inappropriate prescribing were about 43% in both the control group and the intervention group before the intervention began. During the intervention, the rate of inappropriate prescribing decreased in the intervention group to 33.7% but increased in the control group to 52.7%. And the effect of the intervention was sustained each month the letter remained posted.
These results are remarkably better than seen with interventions attempting to reduce inappropriate prescribing with education, audit and feedback, financial incentives, CPOE alerts and reminders, or even simple posters. The authors note that the two most prevalent models for prompting performance improvement, audit/feedback and pay-for-performance, rely on assumptions about clinician behavior that may not be adequate. Their proposed model is one in which clinicians are influenced by interpersonal factors and, in particular, “a desire to remain consistent with a prior public commitment”.
The authors do acknowledge that the patients’ response to the posted letter may also have played a role. Hence the question of who was actually “nudged”. But the bottom line is that it doesn’t really matter whether it was the clinician, patient, or both who were most influenced by the intervention. It’s the outcome that matters.
We think there were two important factors here contributing to the good outcomes. One is the public commitment. The other relates to timing.
The powerful influence of the public commitment cannot be overestimated. In our September 28, 2010 Patient Safety Tip of the Week “Diagnostic Error” we mentioned anchoring becomes a more significant problem once a diagnosis or other decision has been declared publicly. Many of you may have done an exercise in executive training where a scenario is presented in which you must state a position publicly. You are then given a bit of disconfirming evidence and a chance to change your decision. Almost no one changes their decision! (The scenario is actually a poorly disguised parallel of the Challenger disaster).
A number of years ago we began to alert physicians when they prescribed for a geriatric patient a drug appearing on Beers’ list as a potentially inappropriate medication (PIM). The physician almost never took that particular patient off the drug but may in the future be less likely to prescribe that drug in other geriatric patients. In a way, he/she had made a “public commitment” to that particular patient to use that drug (though there are certainly legitimate reasons one might choose to continue a medication that could be a PIM) and was unlikely to change that decision.
Though the above two examples show how the public commitment may have negative consequences, they do demonstrate how strong the public commitment phenomenon is. So we concur with Meeker and colleagues that the public commitment is likely a key driver of the success they saw in their intervention.
But the timing is critical, too. An alert that pops up on a computer screen when the clinician is in the process of prescribing a medication almost always occurs after the clinician has already discussed his plans with the patient. And, as above, the clinician is very unlikely to reverse a previously “publicly” committed position.
In our January 2012 What’s New in the Patient Safety World column “Need for New Transfuion Criteria” we noted a study (Scheurer 2010) that showed little impact on appropriateness of transfusions 2 years after transfusion guidelines were instituted and clinical decision support tools implemented within CPOE. The authors felt that this study showed that the decision to transfuse had “already been made” prior to the CPOE so that, in effect, the clinical decision support was rendered too late. (They also felt that CPOE targeted the intern or more junior resident in most cases and might be better directed toward the more senior clinicians making the decision to transfuse.)
But perhaps the biggest message from the Meeker study is that small changes may have a big impact. Our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impact” we reviewed the book “Nudge” by Richard Thaler and Cass Sunstein (Thaler 2008) and gave some examples of the usefulness of “nudges” in healthcare.
One example we give is ensuring that your staff having patient contact are appropriately immunized against influenza. You can substantially increase your immunization rates by not only providing the immunization free but by having a nurse go out and give the staff their shots right where they are working. The point is that the simple “nudge” makes it easier for them to do the right thing.
We often use the nudge principle in design of various CPOE screens. Making the most desirable (from a quality perspective) choices the default choices is one example. Our August 6, 2013 Patient Safety Tip of the Week “Let Me Sleep!” noted use of the default option as one way to get physicians to order a protocol to reduce sleep interruptions in hospitalized patients.
Of course, several commercial laboratories have utilized “nudges” to their advantage. By placement of items on their requisition slips they make it easier for clinicians to order vitamin D levels and a variety of allergy tests of dubious value that are quite profitable to the labs.
One can argue whether the intervention by Meeker and colleagues is a “nudge” or whether the “public commitment” is the real driver of change. We happen to think that both are true. However, we also think that if we are going to change prescribing or ordering behaviors the intervention needs to occur at a time and place where the clinician is with the patient. If you wait until the clinician picks up his/her pen or mouse you are probably too late in the game to facilitate a change.
The real contribution made by Meeker and colleagues is that relatively simple and inexpensive interventions can produce significant changes. And they demonstrated that you can test those interventions in a randomized fashion in a clinical setting. Purists will say we need now to replicate their findings in similar settings and other settings. But we’re willing to bet that those results will be replicated.
References:
Meeker D, Knight TK, Friedberg MW, et al. Nudging Guideline-Concordant Antibiotic Prescribing. A Randomized Clinical Trial. JAMA Intern Med 2014; Published online January 27, 2014
http://archinte.jamanetwork.com/article.aspx?articleid=1815102
Scheurer DB, Roy CL, McGurk S, Kachalia A. Effectiveness of Computerized Physician Order Entry with Decision Support to Reduce Inappropriate Blood Transfusions. JCOM 2010; 17(1): 17-26
http://www.turner-white.com/jc/abstract.php?PubCode=jcom_jan10_transfusions
Thaler RH, Sunstein CR. Nudge. Improving Decisions About Health, Wealth, and Happiness. New Haven: Yale University Press, 2008
http://www.amazon.com/Nudge-Improving-Decisions-Health-Happiness/dp/014311526X
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February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
The Joint Commission has revised its standards and requirements for hospitals offering diagnostic imaging services (The Joint Commission 2013) and the focus is on patient safety. The revised requirements become effective July 1, 2014 and there will be additional changes coming for 2015.
Hospitals generally underappreciate the patient safety risks in the Radiology suite. While some of those risks are related to the radiology procedures themselves, there are a whole host of risks not directly related to the procedure. We strongly recommend you read our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?” for an exhaustive review of all those risks.
The new Joint Commission requirements focus heavily on MR, CT and nuclear medicine imaging. For MR imaging they want to be sure hospitals manage the risks associated with claustrophobia or anxiety, potential need for urgent or emergent medical care, acoustic noise, patient implants or foreign bodies, and ferromagnetic objects entering the MRI environment. They want you to ensure that access is restricted for everyone not specifically trained in MRI safety (or screened by MRI-trained staff before entering the scanner area), with appropriate signage and direct supervision and control of the area by MRI-trained staff.
Safety in the MRI unit is a whole topic unto its own. We refer you to our prior columns on patient safety issues related to MRI:
The new Joint Commission performance improvement standards also require that hospitals collect data on patient burns occurring during MRI exams, incidents where ferromagnetic items have entered the MRI scanner room, and any injuries resulting from presence of ferromagnetic items in the MRI scanner room.
A focus on radiation safety for both patients and staff is evident in the requirements for CT, nuclear medicine, and PET imaging. Staff dosimetry results need to be reviewed at least quarterly by the radiation safety officer or medical physicist to ensure that staff radiation exposure meets ALARA (“As Low As Reasonably Achievable”) and regulatory limits.
For CT services the hospital needs to measure the actual radiation dose produced for at least adult brain, adult abdomen, pediatric brain, and pediatric abdomen studies and needs to record in the patient’s medical record the radiation dose on every study produced during a CT examination. In addition, the interpretive report of the study needs to include information about the radiation dose.
An important addition is that the hospital considers the patient’s age and recent imaging studies when deciding on the most appropriate type of imaging and has knowledge of recent imaging examinations in order to avoid unnecessary duplication of studies (see our multiple columns on radiation safety and the Imaging Gently® and Imaging Wisely® campaigns listed below). Hospitals are also expected to use external benchmarks for comparison when analyzing its patient CT radiation doses and CT imaging protocols need to be reviewed and kept current, ensuring they are in keeping with current standards of practice and have received input from interpreting radiologists, medical physicists, and the lead imaging technologist.
At the same time, however, maintenance of image quality is important and both radiation dosing issues and image quality issues need to be part of the organizations quality improvement activities.
Also, at least annually a medical physicist or MRI scientist must conduct a performance evaluation on the MR, CT, nuclear medicine or PET equipment. The Joint Commission document lists the parameters that, at a minimum, must be evaluated for each modality. Such persons must also be involved regarding safety issues related to installation of any new equipment, replacement of existing equipment, modifications to rooms where ionizing radiation will be emitted or radioactive materials stored.
The requirements also focus on qualifications of individuals involved in imaging studies, looking for appropriate certification for both radiologic technologists and the medical physicists. It also requires verification that imaging technologists who perform CT have ongoing education that includes training on dose reduction techniques and the Imaging Gently® and Imaging Wisely® campaigns.
Under medication safety standards Joint Commission requires that before administering a radioactive pharmaceutical for diagnostic purposes, staff verify that the dose to be administered is within 20% of the prescribed dose (or within a prescribed range if the dose is prescribed as a range).
Hospitals and imaging centers are expected to perform prior to initiation of a procedure verifications of the correct patient, correct imaging site, correct patient positioning, and (for CT scanning) correct imaging protocol and scanner parameters.
We continue to have a special concern about hospitals that technically do not offer MRI services but either have an arrangement for MRI services provided by third parties on their premises or for those hospitals that don’t have MRI services but have their staff accompany patients to off-site MRI units. While they might be technically exempt from the Joint Commission MRI-specific Joint Commission requirements they need to be cognizant of all the patient safety (and staff safety) issues regarding MRI. We find that such arrangements often result in both parties assuming that someone else is responsible for safety and are especially risk-prone. Similarly, particularly with MRI you need to consider what outside parties (eg. firemen, police) might have to rarely venture into the MRI suite and ensure that they are aware of all the safety precautions that are necessary.
Now is a good time to review your hospital’s compliance with these updated and revised Joint Commission requirements. It’s also a good time to see how your hospital stacks up regarding the numerous safety hazards noted in our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?”.
Some of our prior columns on patient safety issues in the radiology suite:
Some of our previous columns on the issue of radiation risk:
References:
The Joint Commission. Prepublication - Diagnostic Imaging Services Requirements
Prepublication Standards. December 20, 2013
http://www.jointcommission.org/standards_information/prepublication_standards.aspx
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March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
In our January 28, 2014 Patient Safety Tip of the Week “Is Polypharmacy Always Bad?” we discussed the need to consider polypharmacy in the context of the number of comorbidities a patient has. And we pointed out that some of the adverse consequences traditionally associated with polypharmacy may actually be the result of underprescribing! So we said what we really need to strive for is “eupharmacy”, where patients are treated with medications based upon the medical evidence base.
But one of the problems we have in dealing with the elderly is that the evidence base is limited. Particularly for patients age 80 and older there is often a paucity of evidence because such patients are often excluded from randomized controlled trials. For some preventive medications that absolute risk reduction may be much different at age 80 than it is at age 50 or 60.
So a provocative recent perspective in the journal Evidence-Based Medicine (Byatt 2014) is very timely in that respect. The author looked at the evidence base for medications used to prevent stroke in patients over 80 and noted that by this age hypertension may no longer be an attributable risk factor for stroke. Similarly, the use of statins in this age group has only marginal reduction in stroke risk and modest reduction in overall cardiovascular events.
Byatt notes that the NNT (number needed to treat) with antihypertensives for 2 years to prevent one stroke is 94 and the NNT to prevent nonfatal strokes even higher. For statins, treatment in the elderly reduces the risk of a composite of all strokes or cardiac events but not strokes alone.
The numbers noted by Byatt for antihypertensive therapy come from the HYVET (Hypertension in the Very Elderly Trial) study (Beckett 2008). That study did show that treatment of hypertension in patients age 80 and older resulted in a 30% reduction in the rate of fatal or nonfatal stroke and a 39% reduction in the rate of death from stroke. Also, in contrast to several other studies, it demonstrated a reduction in the rate of death from any cause (21% reduction). But overall the study population in HYVET was relatively healthy. Only 11.8% had a history of cardiovascular disease. So it is very difficult to extrapolate the beneficial effects noted in HYVET to the frail elderly.
For many years we have said that the benefits of statin use are actually more pronounced in the very elderly. But that is where we need to make a distinction between primary and secondary prevention. They may be beneficial in a patient who has already had a cardiovascular event but may have a much more limited benefit when used as primary prevention at this age.
At the same time the Byatt perspective came out another study (Tinetti 2014) was published looking at the impact of antihypertensive therapy on serious fall-related injuries in the elderly. They looked at a nationally representative sample of community-dwelling Medicare patients older than 70, most of whom had multiple comorbidities and were therefore representative of the real world as opposed to the relatively healthy patients in randomized controlled trials. Compared to patients on no antihypertensive medications those with moderate-intensity antihypertensive therapy were 40% more likely to have a serious fall-related injury and those on high-intensity antihypertensive therapy 28% more likely to have a serious fall-related injury. Also, those with a history of a prior fall injury were over twice as likely to suffer a fall-related serious injury. The authors chose serious fall-related injuries (hip fractures, other serious fractures, head injuries, etc.) because the consequences of these are comparable to the consequences of the conditions they are being used to prevent (eg. stroke, cardiovascular conditions).
The Tinetti paper is another reminder that in the real world we need to balance the potential risks against the potential benefits when we consider treatment of various risk factors. What works well in relatively healthy subjects seen in randomized controlled trials may not have the same risk:benefit ratio seen in elderly patients with multiple chronic conditions.
Patients such as those in the Byatt and Tinetti papers are not likely first starting their medications in their 70’s and 80’s. In most cases they have likely been on them for many years. Sometimes it is difficult to ascertain who originally prescribed the medication and why. So the real question is “when should we consider stopping medications?” and the next question is “how do we go about stopping them?”.
Fortunately, some good work has already been done addressing the issue of deprescribing in the elderly. Ian Scott and colleagues (Scott 2012) developed a 10 step conceptual framework for minimizing inappropriate medications in older populations and deprescribing (if you don’t have full access to that journal you can read an interview with Dr. Scott (Brookes 2013) in Medscape):
Deprescribing can be very time-consuming and often requires coordination with many other providers. Scott suggests only deprescribing one medication at a time. Another article on deprescribing in elderly nursing home patients (Liu 2014) also notes you need to observe patients for withdrawal syndromes or discontinuation syndromes when certain medications are tapered or discontinued.
We’ve noted in many of our columns that when we do medication reviews on elderly patients we almost always identify at least 1-2 medications that might be discontinued. In some cases there may be therapeutic duplication. In others it may be a potentially inappropriate medication from Beers’ list or the STOPP list. Those instances are actually the easy ones in which we can begin deprescribing. The tougher ones are those in which the patient is on a preventive medication. That’s when we must determine the patient’s real risk of developing the condition within his/her expected lifespan and whether the evidence is there to suggest the medication truly prevents that condition at this age. We then need to consider the potential adverse effects that medication might have and do an individualized risk:benefit analysis for that patient. We find most patients are willing to consider deprescribing when you have this sort of informed conversation with them. They (and more often the provider) may fear that stoppage of that medication will result in the condition they were trying to avoid. You do have to let them know that is a possibility but when you weigh the potential harms against the potential benefit (using terms they can understand, not statistical terms like “relative risk reduction”!) most are willing to consider coming off even a preventive medication.
So the bottom line: don’t just consider medications as potentially inappropriate if they are on Beers’ list or the STOPP list. Consider all medications as potentially inappropriate in the very elderly and do the sort of analyses noted above to determine whether deprescribing may be an option for your individual patient.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Patient Safety Tips of the Week:
What’s New in the Patient Safety World columns:
References:
Byatt K. Overenthusiastic stroke risk factor modification in the over-80s: Are we being disingenuous to ourselves, and to our oldest patients? (Perspective). Evid Based Med 2014; doi:10.1136/eb-2013-101646 Published Online First: 26 February 2014
http://ebm.bmj.com/content/early/2014/01/15/eb-2013-101646.short?g=w_ebm_ahead_tab
Beckett NS, Peters R, Fletcher AE, et al. for the HYVET Study Group. Treatment of Hypertension in Patients 80 Years of Age or Older. N Engl J Med 2008; 358: 1887-1898
http://www.nejm.org/doi/full/10.1056/NEJMoa0801369
Tinetti ME, Han L, Lee DSH, et al. Antihypertensive Medications and Serious Fall Injuries in a Nationally Representative Sample of Older Adults. JAMA Intern Med 2014; Published online February 24, 2014
http://archinte.jamanetwork.com/article.aspx?articleid=1832197
Scott IA, Gray LC, Martin JH, Mitchell CA. Minimizing inappropriate medications in older populations: a 10 step conceptual framework. Am J Med 2012; 125: 529–537
http://www.amjmed.com/article/S0002-9343%2811%2900901-6/abstract
Brookes L, Scott IA. Deprescribing in Clinical Practice: Reducing Polypharmacy in Older Patients. An Expert Interview With Ian A. Scott, MBBS, FRACP, MHA
Medscape Internal Medicine. November 26, 2013
http://www.medscape.com/viewarticle/814861
Liu LM. Deprescribing: An Approach to Reducing Polypharmacy in Nursing Home Residents. Journal for Nurse Practitioners 2014; 10(2): 136-139
http://www.npjournal.org/article/S1555-4155%2813%2900590-4/abstract
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March 11, 2014
We Miss the Graphic Flowchart!
In our Patient Safety Tips of the Week for December 29, 2009 “Recognizing Deteriorating Patients” and September 11, 2012 “In Search of the Ideal Early Warning Score” we lamented the fact that, ironically, the switch from paper to electronic health records may have made it more difficult to identify deteriorating patients. Some of the EMR’s don’t provide easy access to a graphic flow chart similar to the paper vital signs flowchart that always sat on top of the patient chart.
Apparently we’re not the only ones who miss the graphic flowchart! This month an article on implementation of an early warning system echoed the same problem (Fung 2014). When a hospital implemented their new system they used a new form that, unlike their prior form, did not represent the vital signs and other physiological parameters in a trend graph form. Because of concerns about the lack of such graphic representation, the authors developed scenarios to test their hypothesis that the lack of such representation might make it harder to identify clinical deterioration. Six clinical scenarios (low-grade temperature, spiking temperature, tachypnea, Cushing’s response, hypovolemic shock and normal observations) were identically depicted on old and new charts and given to one hundred health-care professionals who were asked to study each of the charts, and the time taken to give a diagnosis was recorded.
The old chart (the one with the graphic display) was associated with faster responses in all of the scenarios, reaching statistical significance in 5 of the 6 scenarios. Additionally, the response was more accurate in all of the scenarios, reaching statistical significance in 3 of the 6 scenarios. Overall, response to the old chart was 1.6 times faster and 15% more accurate than the new chart!
And the lack of a graphic display affects things other than early warning systems. In our May 28, 2013 Patient Safety Tip of the Week “The Neglected Medications: IV Fluids” we noted that problems managing fluid status may have actually worsened as an unintended consequence of technology. In the old days, the first thing we saw when we opened a patient’s chart or walked into their room was a flow sheet that had their vital signs, their I&O’s (input and output), and their weight all represented in graphic form. It was pretty easy to spot bothersome trends. Many of today’s EHR’s, however, don’t provide such graphically displayed data (or at least don’t make it easy to get to such displays in just a click). Theoretically, computers should make it easier to track fluid status. The computer should be able to be programmed to compare the fluid input to the measured output and perform a calculation of the estimated insensible losses, then display the net fluid deficit or excess in a graphic form along with the patient’s weight. You could even program in alerts when deficits or excesses are above whatever limit you set (or at least display those unwanted values in red), keeping in mind we want to avoid alert fatigue.
Similarly, on the outpatient side, some diagnostic errors might be avoided if there were better graphic display of some parameters (see our May 15, 2012 Patient Safety Tip of the Week “Diagnostic Error: Chapter 3”). For example, it is often difficult to recognize that a patient has had a significant weight loss when you typically just look at the last visit note and compare the weight from that visit to today’s visit. Putting patient weights in graphic form may help us recognize trends (weight gain or loss) that may be significant clues or red flags about the patient’s condition.
Add to the problem the notorious fact that nurses’ notes go largely unread by physicians in the EHR (see our March 22, 2011 Patient Safety Tip of the Week “An EMR Feature Detrimental to Teamwork and Patient Safety”) and it’s no wonder signs of clinical deterioration get missed.
Simply put – some things are more easily recognizable when they are in graphic form. So IT vendors: get with it!!! Computers should easily be able to represent these parameters in a graphic format. They should also be able to highlight significant trends in red or other bright color to draw our eye to such trends. And they need to make these graphic flowcharts readily accessible. If it takes more than 2 mouse clicks to get to them, they will be underutilized.
Visual display of early warning system data has been used successfully (Rothman 2013, Finlay 2014). The Rothman Index (RI) is a composite measure of 26 variables readily available in most EMR’s. Variables include input from vital signs, laboratory values, cardiac rhythm, the Braden Scale, and nursing assessment and the RI can be updated automatically every time new clinical information is input. The RI can be displayed graphically to alert clinicians to acute changes in patient status as they happen (Rothman 2013). A recent study (Finlay 2014) demonstrated the RI to be superior to the MEWS in several respects.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
Some of our other columns on early warning systems or recognition of clinical deterioration:
References:
Fung K, Khan F, Dawson J.The Introduction of an Integrated Early Warning Score Observation Chart–A Picture Paints a Thousand Words. Journal of Patient Safety 2014; 10(1): 13–19
Rothman MJ, Rothman SI, Beals J. Development and validation of a continuous measure of patient condition using the Electronic Medical Record Original Research Article
Journal of Biomedical Informatics 2013; 46(5): 837-848
Finlay GD, Rothman MJ, Smith RA. Measuring the modified early warning score and the Rothman Index: Advantages of utilizing the electronic medical record in an early warning system. Journal of Hospital Medicine 2014; 9(2): 116–119,
http://onlinelibrary.wiley.com/enhanced/doi/10.1002/jhm.2132
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March 18, 2014
Systems Approach Improving Stroke Care
Despite almost 20 years since studies demonstrated the beneficial effect of thrombolytic therapy for actue ischemic stroke if given within a relatively narrow therapeutic window we have continued to struggle to get that therapy to eligible patients. While some of the factors preventing that are patient-related, others are related to poor system design and bottlenecks in our current systems.
Our November 6, 2012 Patient Safety Tip of the Week “Using LEAN to Improve Stroke Care” highlighted studies that used the LEAN/Toyota Production System approach to streamline the processes and achieved a dramatic reduction in the door-to-needle time for thrombolytic therapy in acute ischemic stroke patients (Ford 2012, Panagos 2012).
Another healthcare organization has similarly re-engineered its protocols and systems to produce striking reductions in door-to-needle times and significantly increase the perecentage of eligible stroke patients getting thrombolytic therapy (Binning 2014). Capital Health, which operates 2 neurological emergency departments in New Jersey, cut its door-to-needle time by over 50% and increased the percentage of patients receiving tPA to 18% from their historical rate of 5%. Key to their success was bypassing the emergency department and bring the patient directly to the CT suite. This was accomplished by extensive training of the pre-hospital EMT community in recognition of stroke. The EMT’s were then able to alert the hospital they had a patient with potential stroke, which then triggered a sequence of events that resulted in the patient going directly to CT where he/she was met by a team of individuals involved in stroke care.
The physicians responding to the CT suite were not neurologists or neurosurgeons. Rather they were emergency department physicians trained in the assessment of the patient with stroke and able to administer IV tPA. Just as we saw long ago with thrombolytic therapy for acute MI, waiting for the specialist to give his/her blessing to thrombolytic therapy created a bottleneck. We now see the same for thrombolytic therapy for stroke. It’s pretty clear that well-trained ED physicians can expedite thrombolytic therapy for eligible stroke patients. The “neurologic” ED physician confirms the diagnosis of stroke and awaits the CT result to determine if tPA should be given.
But the improvements in the Binning study needed contributions from the entire team. Once the EMS alert comes in, a blast page goes out to the CT technician, a designated ED neurological nurse, the ED charge nurse, registration, and pharmacy, in addition to the neurological ED physician. Just as seen in the studies highlighted in our November 6, 2012 Patient Safety Tip of the Week “Using LEAN to Improve Stroke Care” a second bottleneck was getting necessary laboratory results promptly. So ensuring blood specimens are drawn promptly on patient arrival to the CT suite is important. One impediment we’ve seen over and over at hospitals is archaic registration procedures that lead to unnecessary delays in both the CT imaging and the bloodwork. Their protocol starts the patient registration process even before the patient arrives and having someone from registration as part of the team is important. Orders for the CT scan and laboratory studies are entered even prior to patient arrival. Similarly, having pharmacy available to ensure availability of the tPA is important.
The average time between patient arrival and acquisition of CT imaging was 11.8 minutes, compared to 35 minutes in the era prior to these protocols. Their median door-to-needle time was 44 minutes (average door-to-needle time was 56.5 minutes). Results were even better if 3 outliers were excluded (these were patients in whom significant delays were due to patient-related factors rather than system issues), resulting in average door-to-needle time of 46.1 minutes. In fact, their 3 fastest door-to-needle times were 12, 16, and 18 minutes!
Most importantly, 18% of eligible patients received thrombolytic therapy within the accepted therapeutic window. Nationwide we’ve historically seen less than 5% of eligible patients get thrombolytic therapy.
The EMT’s were actually quite good at recognizing sroke patients. Their diagnosis of stroke was accurate 66% of the time and their recognition that the patient had a neurological problem was 89% accurate. Those numbers are similar to experiences elsewhere in the country and their list of the other conditions mimicking stroke is similar to what we’ve seen elsewhere.
To summarize key elements of the system:
The Binning paper does not mention any untoward consequences of their system. They do mention that some patients were too unstable to go directly to CT. We will just caution you to remember the whole host of things that can go wrong in your radiology suite (see our October 22, 2013 Patient Safety Tip of the Week “How Safe is Your Radiology Suite?” and its links to all our previous columns on adverse events in the radiology suite).
Actually the hospitals in today’s column and our November 6, 2012 Patient Safety Tip of the Week “Using LEAN to Improve Stroke Care” are not the only ones improving stroke care and outcomes. Results of the large Target: Stroke iniative at over 1000 hospitals participating in the Get With The Guidelines (GWTG) program of the American Heart Association/American Stroke Association were just presented at the International Stroke Conference 2014 (Fonarow 2014, presentation slides). That initiative resulted in a reduction of median door-to-needle time for tPA from 74 minutes to 59 minutes and an increase in the percentage of patients receiving tPA within 60 minutes from 29.6% to 53.3%. Even more impressive are the results of clinical outcomes that showed statistically significant improvements in in-hospital mortality, discharge to home, independent ambulatory status, and a reduction in tPA complications and symptomatic intracerebral hemorrhages.
The presentation slides from Fonarow and colleagues list the 10 key best practice strategies used in the Target: Stroke iniative that were previously published (Fonarow 2011):
The presentation slides from Fonarow and colleagues also have links to customizable implementation tools used by hospitals in the Target: Stroke initiative.
These are great example of how re-engineering our systems of care can result in significant improvements in patient outcomes.
But all these results pale in comparison to those achieved in Finland. In the Binning study we noted they had 3 patients in whom the door-to-needle time was less than 20 minutes. How about achieving a median door-to-needle time of 20 minutes or less? That’s exactly what the teams in Helsinki, Finland did (Meretoja 2012). They were able to achieve a median door-to-needle time of 20 minutes and 94% of their patients were treated within 60 minutes!
How did they do it? They implemented 12 measures over a period spanning 1998 to 2005:
The healthcare delivery system in Helsinki has a couple characteristics that helped achieve these great results. One is the community-wide EMR that allowed the stroke teams to review the patient history prior to arrival at the hospital. Second is the set up that prioritized getting stroke patients to a specific hospital. In New York State we originally envisioned a stroke triage system similar to our trauma system, in which patients would get taken to designated stroke centers. However, pressure from hospitals and the EMS community resulted in stroke centers popping up at most hospitals. While theoretically getting a patient to the closest hospital should reduce the time from symptom onset to thrombolytic therapy, that has yet to be demonstrated. The Meretoja paper discusses the conflicting data on impact of short onset-to-arrival times (noting also that times to treatment are often paradoxically increased in patients having in-hospital strokes). In their system a whole lot gets accomplished while the patient is in transit in the ambulance. So one might make the case that a few minute delay in getting the patient to a hospital with a proven track record of efficiency in stroke care may be less important.
One important aspect in thrombolytic therapy is having an accurate history (usually from family or other witnesses) about the onset of stroke symptoms. Getting such history, particularly when the patient himself is unable to provide it, can cause significant delays. Having the prenotification call go directly to the stroke physician facilitated getting the stroke physician in contact with witnesses capable of providing such history.
When the prenotification came in from EMS, the stroke team ER nurse was also alerted and ensured that the CT table was available immediately and that personnel for laboratory studies were there at patient arrival. They noted that the only 2 labs that were critical were the blood glucose level and the INR (international normalized ratio). The EMS team was able to do point-of-care (POC) glucose testing in the field. A switch to POC INR testing at the hospital provided the INR result in about a minute.
They also found that delays in the past were often caused by doing angiograms or perfusion studies and that most patients did not need these. So they developed protocols to include such imaging only in cases where the decision about tPA could not be made without them.
The authors concluded “the key to success in reducing the delays is to do only the basics while the patient has arrived, and to do as much as possible before, during transport.”
While the authors did not have detailed neurological outcome data available when they wrote that 2012 paper, they have just published a study estimating the impact of this faster stroke care (Meretoja 2014). They conclude that each minute of onset-to-treatment time (OTT) saved translates to 1.8 days of extra healthy life and that each 15-minute decrease in delay provides an average of 1 month of additional disability-free life. They observed a benefit in all age groups, with slightly more benefit in younger and female patients over a lifetime.
The editorial accompanying the 2012 Meretoja paper (Smith 2012) lauds the work done by the teams in Finland but does caution that enough time be reserved for accurate clinical evaluation and identification of contraindications to thrombolytic therapy. They stress that patient safety must not be sacrificed for the sake of speed. We agree and again caution you to remember the whole host of things that can go wrong in your radiology suite (see our October 22, 2013 Patient Safety Tip of the Week “How Safe is Your Radiology Suite?” and its links to all our previous columns on adverse events in the radiology suite).
So how does your stroke care stack up against these results?
References:
Ford AL, Williams JA, Spencer M, McCammon C, Khoury N, Sampson TR, Panagos P, Lee J-M. Reducing Door-to-Needle Times Using Toyota’s Lean Manufacturing Principles and Value Stream Analysis. Stroke. 2012; 43: 3395-3398 published online before print November 8 2012
https://stroke.ahajournals.org/content/43/12/3395.abstract?sid=420c9dbd-a01c-4842-af76-f239d50891e5
Panagos P, Ford A, Williams J, Khoury N, Sampson T, McCammon C, Lee J-M. Applying Toyota Lean Manufacturing Principles to Stroke Care: Accelerating Door-to-Needle Times. AHA (American Heart Association) International Stroke Conference 2012. February 2012 (ISC 2012 New Orleans)
http://conference-cast.com/aha/media/AHA2012ISC_7/A26/3497/3497.pdf
Binning MJ, Sanfillippo G, Rosen W et al. The Neurological Emergency Room and Prehospital Stroke Alert: The Whole Is Greater Than the Sum of Its Parts. Neurosurgery 2014; 74(3): 281–285
Fonarow GC, Zhao X, Smith EE, et al. Improving Door-To-Needle Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative. International Stroke Conference 2014; Presentation Number: LB12
Presentation slides
Fonarow GC, Smith EE, Saver JL, et al. Improving Door-to-Needle Times in Acute Ischemic Stroke: The Design and Rationale for the American Heart Association/American Stroke Association's Target: Stroke Initiative. Stroke 2011; 42: 2983-2989
https://stroke.ahajournals.org/content/42/10/2983.full
Meretoja A, Strbian D, Mustanoja S, et al. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology 2012; 79: 306–313
http://www.neurology.org/content/79/4/306.abstract
Meretoja A, Keshtkaran M, Saver JL, et al. Stroke Thrombolysis: Save a Minute, Save a Day. Stroke 2014; published online March 13, 2014
https://stroke.ahajournals.org/content/early/2014/03/13/STROKEAHA.113.002910.full.pdf+html
Smith EE, von Kummer R. Door-to-needle times in acute ischemic stroke. How low can we go? (editorial). Neurology 2012; 79: 296-297
http://www.neurology.org/content/suppl/2012/07/22/WNL.0b013e31825d6011.DC3/znl02812000296.pdf
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March 25, 2014
Melatonin and Delirium
We’ve done numerous columns on recognition, prevention, and management of delirium (see list at the end of today’s column). Pharmacological interventions to prevent delirium have been disappointing. The most successful interventions have been multimodality ones and, even then, benefits have been modest. One of the mainstays of those multimodalitiy interventions has been the attempt to maintain sleep-waking cycles as close to normal as possible. So it was only a matter of time until someone would attempt to use melatonin, the pineal gland hormone important in regulation of sleep-waking cycles, to prevent delirium.
There have been a few old studies and a new study looking at melatonin as a potential intervention to prevent delirium in hospitalized patients.
In a study of 300 elderly patients undergoing hip arthroplasty, Sultan (Sultan 2010) randomized patients to 4 arms of sedation (none, melatonin, midazolam, and clonidine). Only 9.4% of patients in the melatonin arm developed post-op delirium, compared to 32.7% of those in the control arm. In addition, 58% of those who developed post-op delirium were successfully treated with melatonin.
Another small (n = 145) randomized controlled study evaluated low dose melatonin in elderly patients admitted to an acute medical service (Al-Aama 2011) found that melatonin was associated with a lower risk of delirium (12.0% vs. 31.0%).
In the new study Hatta and colleagues did a multicenter randomized controlled trial of ramelteon, a melatonin agonist, in elderly patients in ICU’s and acute care wards to see if it could prevent delirium (Hatta 2014). Patients were 69-89 years old, were admitted for acute medical problems, had an expected length of stay and life expectancy longer than 48 hours, and had to be able to take oral medications. Patients on certain medications or with certain other conditions were also excluded. In fact, of 1126 patients assessed for eligibility, 1059 were excluded. Ultimately, 67 patients were randomized to receive either placebo or ramelteon.
Ramelteon was associated with a lower risk of delirium (3% vs 32%; p =0.003), with a relative risk of 0.09. Even after risk factors were controlled for, ramelteon was still associated with a lower incidence of delirium (odds ratio 0.07). Interestingly, though the difference in delirium incidence was great, measured sleep parameters did not differ between those in the two study arms.
Though the number of patients in this study met the authors’ power analysis, its conclusions are limited by the fact that this is a very small sample size. The study was also not double-blinded. The raters were blinded but patients were not and the placebo apparently differed in appearance from the active medication. There was also substantial cessation of medication before the planned 7 days in both arms. And the huge number of excluded patients is of concern.
Call us skeptics when it comes to all 3 of these studies. We are of the John Ioannidis school of thought that says “if it sounds too good to be true, it probably is not true” (Ioannidis 2005, Pereira 2012). Those authors conclude that most large treatment effects emerge from small studies, and when additional trials are performed, the effect sizes become typically much smaller.
So don’t run out and start treating your at-risk patients with melatonin or melatonin agonists yet. Nevertheless, given the serious implications of delirium and our currently limited interventions to prevent it, these studies pose a hypothesis that should be tested in well-designed randomized controlled trials. Stay tuned.
Some of our prior columns on delirium assessment and management:
References:
Al-Aama T, Brymer C, Gutmanis I, et al. Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry 2011; 26(7): 687-694
http://onlinelibrary.wiley.com/doi/10.1002/gps.2582/abstract
Sultan SS. Assessment of role of perioperative melatonin in prevention and treatment of
postoperative delirium after hip arthroplasty under spinal anesthesia in the elderly. Saudi J Anaesth 2010; 4(3): 169-173
Hatta K, Kishi Y, Wada K, et al. for the DELIRIA-J Group. Preventive Effects of Ramelteon on DeliriumA Randomized Placebo-Controlled Trial. JAMA Psychiatry 2014; Published online February 19, 2014
http://archpsyc.jamanetwork.com/article.aspx?articleid=1831407
Ioannidis JP. Why most published research findings are false. PLoS Med 2005; 2(8): e124
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020124
Pereira TV, Horwitz RI, Ioannidis JPA. Empirical Evaluation of Very Large Treatment Effects of Medical Interventions. JAMA 2012; 308(16): 1676-1684
http://jama.jamanetwork.com/article.aspx?articleid=1386610
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Lessons from Canadian Analysis of Medical Air Transport Cases
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
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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