Healthcare Consulting Services
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
Periodically, we discuss the investigation or root cause analysis of a disaster in an industry other than healthcare. Most often that is regarding an accident in the aviation or other transportation industry. We do this because the typical cascade of human and system errors and root causes that come to light are so similar to those that occur in healthcare incidents that result in patient harm. Hopefully, the lessons learned from these accidents may be used to avert similar incidents in healthcare.
AirAsia Flight QZ8501 crashed into the Java Sea on December 28, 2014, killing all 162 people aboard (KNKT 2015). It was cruising at 32,000 feet on a flight from Indonesia to Singapore when the cascade of precipitating events took place. The weather and meteorological conditions did not appear to be factors. The pilot in charge had over 20,000 hours of flying experience and the second-in-command over 2000 flying hours, most in the Airbus 320, the type of aircraft involved in the crash. Both had passed their last proficiency checks in the month prior to the crash. Though there was an issue regarding approval for flight (an issue about what days this airline could fly), that did not appear to be a factor in the crash.
At the center of the cascade: cracked soldering on a small circuit board. This was on the Rudder Travel Limiter Unit (RTLU). There was cracking of a solder joint of two channels that resulted in loss of electrical continuity and led to RTLU failure. Maintenance records showed that there had been 23 Rudder Travel Limiter problems starting from January 2014 to 27 December 2014 and that the interval of the malfunctions became shorter in the last 3 months even though maintenance actions had been performed since the first malfunction was identified in January 2014.
Just 3 days prior to the day of the accident one of the pilots of the fatal flight was flying another flight on this aircraft and had problems with an alarm indicating RTLU dysfunction. Airline mechanics addressed the problem while the pilot was observing. One of the corrective actions involved pulling and resetting a circuit breaker. The pilot asked if he would be able to do that if the alarm again went off and was told he would be able to if the computer/dashboard message indicated so.
On the fateful day, the Airbus 320 was cruising at 32,000 feet when the alarm regarding the RTLU triggered. In fact, it triggered multiple times. The first 3 times the pilot-in-command (PIC) and the second-in-command (SIC), who was flying the plane at the time (under autopilot), responded appropriately to the alarm and performed the specified actions. The fourth time, however, they did something different – they pulled the circuit breaker.
These events led to disengagement of the autopilot and auto-thrust and meant that the pilot flying (PF) was now manually flying the aircraft. You’ll recall from some of our prior columns the phenomenon of “automation surprise”, a concept describing what happens when computers working in the background cease functioning and multiple factors visible to the computer are not readily apparent to the now manually flying pilot. Some of those factors may include speed of the plane, attitude (orientation to the ground), rotation, etc.
One of the parameters that changed was airspeed. Aerodynamic stalls occur when airplane speed drops below the speed at which airflow over the wings and the “angle of attack” fails to provide the “lift” that keeps the plane airborne. The plane also began to change its attitude and rotation. The “stall” alarm sounded.
Pilots, of course, train for aerodynamic stalls as a core element of their training and preparation for flying and do stall simulations as well. Most stalls, however, occur when a plane is changing speeds or angles of attack such as on takeoffs and landings. Stalls occurring on “level” flying at high altitude cruising are much rarer.
The usual response to an aerodynamic stall is to put the nose downward until lift is restored. This is done via a “stick” or lever next to the pilot that is somewhat like the joystick you might be familiar with on computer games. To go down you push the lever forward. To go up you pull it back. But when the stall began, the PIC (pilot-in-command) yelled “pull down…pull down” (repeated 4 times). This order is ambiguous because if you pull the level/stick down, the plane goes up and accentuates a stall.
In addition, the plane has dual controls in that there is a second stick/lever at the side of the pilot not flying (PNF). But if one stick/lever system is not deactivated both provide input and the net result is the algebraic sum of the action of both sticks/levers. It appears in this incident that the PIC did begin using his stick/lever but it was at the same time the SIC was using his and they were likely moving them in opposite directions, negating the actions of each other. The net effect was that the desired downward angle did not occur. In fact, the nose further rose and the plane began to rotate and spin.
In addition, immediately increasing the thrust of the engines may result in the nose of the plane lifting up, which further accentuates the stall. You may actually need to reduce the thrust temporarily if the nose is not angled down.
Note that this is all somewhat counterintuitive. The natural human response might be to point up and increase the speed. That is why training for such emergencies is critical. The pilots need to have immediate knowledge of what to do in such cases and have practiced it at least in simulation exercises. The pilots were trained and had experience of recovery from the approaching stall. But the condition of stall at zero pitch (as in this instance) had never been trained as the training for stall was always with a high pitch attitude.
The plane was now spinning out of control in what is known as an “upset”. Upset Recovery training was included in the aircraft operators training manual. But the aircraft operator told investigators that the flight crew had not been trained for the upset recovery training on Airbus A320, reflected in the Flight Crew Training Manual “Operational Philosophy”: “The effectiveness of fly-by-wire architecture, and the existence of control laws, eliminates the need for upset recovery maneuvers to be trained on protected Airbus”. (And apparently the regulatory body in Indonesia did not find that to be out of compliance.)
Below we summarize some of the key factors that played a role in this tragic accident. In some cases we provide analogies to healthcare incidents. But, in general, we leave it to your imagination to envision how such human factors and system failures seen in this case might occur every day in various venues in your healthcare system.
In healthcare sentinel events, communication breakdowns contribute in 75-85% or more of events. The same obviously occurs in aviation or other transportation accidents. There were several examples of such miscommunication in the current case.
Prior to removal of the circuit breaker there should have been a discussion between the PIC and SIC about what might happen if and when the circuit breaker was removed. In their training manual there is a chapter on “Computer Reset” that says: “ In flight, as a general rule, the crew must restrict computer resets to those listed in the table. Before taking any action on other computers, the flight crew must consider and fully understand the consequences.” The investigators note this statement was potentially ambiguous to the readers and might be open for multiple interpretations. But had it been followed, the crew might have realized the autopilot would disengage and be prepared for that.
A series of serious miscommunications occurred once the stall alarm triggered. The PIC shouted “level…level…level” (repeated 4 times). But it was not clear whether he meant to level the wings or level the “attitude” or orientation of the plane to the ground. Then he followed with the command to “pull down…pull down” (repeated 4 times). As above, this order is ambiguous because if you pull the level/stick down, the plane goes up and accentuates a stall.
Another miscommunication was one that did not take place but should have. When the PIC began to manipulate his stick/lever, standard operating procedure would have been to call out “I HAVE CONTROL” and responded by the other pilot transferring the control by call out “YOU HAVE CONTROL”. Had that happened, perhaps the cancelling action of operating to sticks/levers simultaneously would not have occurred.
“Hearback” is a feature of good communication that is a critical feature of cockpit resource management. In all likelihood the events in this case unfolded so rapidly that there was not enough time for it. But that is one of the reasons that training and simulation exercises are so important. They prepare you for what to say and do and hear and respond under the most emergent circumstances.
One factor not commented upon in this case that has been a contributing factor in other transportation accidents is language/cultural disparity. The PIC here was Indonesian and the SIC was French. We don’t know whether this might have led to any difficulties in communication. And we are not simply talking about language. In some of the other accidents, hierarchical cultural factors have led to SIC’s being afraid to challenge PIC’s.
Several of our previous columns have discussed automation surprises, whether that is a computer changing things in the background or a system operating with several “modes” controlled via a single switch. Here the obvious automation surprise was not seeing all the issues arising when control of the plane was abruptly turned over to the pilot flying (PF) when the autopilot disengaged.
Most of you have already personally experienced automation surprises. Have you ever been driving on a highway and started slowing down, only to find that the cruise control on your car (you forgot you had set it!) speeds you up?
In healthcare, much of our equipment in ICU’s (and other areas) is high tech and computers are often doing things in the background that we are not immediately aware of. Similarly, we often do have equipment that runs several different “modes” off a single switch. We gave an example of such a surprise back in 2007 when we described a ventilator operating on battery power when all thought it was operating on AC current from a wall socket.
When we talk about alarm fatigue we are usually discussing situations in which the overabundance of clinically irrelevant alarms causes us to ignore alarms that are clinically important. But in this accident one of the proximate causes was the inordinate attention placed upon shutting off the alarm that had previously produced so many false alarms. So it really was a form of alarm fatigue.
Loss of situational awareness
Loss of situational awareness is often a factor contributing to many accidents. In this case, there was some such loss in that the SIC probably was not immediately aware of multiple important flight parameters when the autopilot abruptly disengaged.
Loss of spatial orientation
Loss of spatial orientation occurs in a couple ways. The investigators note “Mulder’s Law” in which there is a threshold (called Mulder’s Constant) below which accelerations are not sensed by the human vestibular system. That certainly might have come into play as the plane spiraled out of control. The other would be not being able to see the horizon or other land structures as the plane nosed upward. Such disorientation has been raised in previous aircraft accidents like the Mt. Erebus crash in the Antarctic or the crash in the Atlantic involving John Kennedy, Jr.
The investigators note that for pilots the main effects of the startle reflex are the interruption of the on-going process and distraction of attention towards the stimulus. These happen almost immediately, and can be quickly dealt with if the cause is found to be non-threatening. However, the distraction can potentially reduce a pilot‟s concentration on flight critical tasks.
When we discuss diagnostic error we note there are numerous cognitive biases (see our numerous columns on diagnostic error). Particularly when we are in the “pattern recognition” or “fast thinking” mode we are more prone to such biases. In this case “availability bias” was likely operative in that the PIC resorted to pulling the circuit breaker because he had recently seen the mechanic do that to fix the faulty RTLU alarm.
In our August 7, 2007 Patient Safety Tip of the Week “Role of Maintenance in Incidents” we noted that many of the most famous disasters in industry history have followed equipment or facilities maintenance activities, whether planned, routine, or problem-oriented. Well-known examples include Chernobyl, Three-Mile Island, the Bhopal chemical release, and a variety of airline incidents and oil/gas explosions. In this case the failure to perform a permanent fix for the faulty circuit board was a critical factor.
In that column we noted James Reason and Alan Hobbs in their 2003 book “Managing Maintenance Error. A Practical Guide” do an outstanding job of describing the types of errors encountered in maintenance activities, where and under what circumstances the various types of error are likely to occur, and steps to minimize the risks.
Failure to prepare for emergencies
Emergencies, particularly those involving events that rarely occur, are ripe for disastrous outcomes if all parties are not prepared to respond appropriately. Pilots use checklists to help them not only with routine procedures but also to help them in many emergent situations. We’ve also discussed the use of checklists for some OR emergencies (see our August 16, 2011 Patient Safety Tip of the Week “Crisis Checklists for the OR” and our February 2013 What's New in the Patient Safety World column “Checklists for Surgical Crises”). In the OR you might have a checklist to help you respond appropriately to an unexpected case of malignant hyperthermia.
But some emergencies, such as that in the current case, merit responses that don’t allow time to consult checklists. They need immediate rehearsed responses that can only be prepared for by simulation exercises or drills. While the pilots in the current case had practiced stall recoveries, they had inadequate training for “level attitude” stalls at high speed and no “upset recovery” training. In healthcare an example needing such training or drills would be a surgical fire.
Other training issues
One very interesting item in the investigation report was that the airline does not practice full “role reversal” in its operations training. In flights there is task sharing and duties allocation between the pilots and copilots, the PIC (pilot-in-command) and SIC (second-in-command), or between the PF (pilot flying) and PNF (pilot not flying) and one sits in the “right-hand seat” and the other in the “left-hand seat”. The implication by the investigators is that it would be very useful during training to have these various actors switch places and roles and get a better understanding of the others’ perspective.
What a novel idea! This is one we most definitely should adopt in some of our simulation exercises in healthcare!
What better example of overconfidence than the Flight Crew Training Manual “Operational Philosophy”: “The effectiveness of fly-by-wire architecture, and the existence of control laws, eliminates the need for upset recovery maneuvers to be trained on protected Airbus”. That’s like saying the Titanic is so well designed and built it will never sink so don’t train for evacuating it.
Other root causes
Most of the above are more proximate causes or contributing factors. But if we dig deeper we undoubtedly would find other root causes. For example, why wasn’t the faulty circuit board simply replaced rather than attempting to just solder it each time when clearly such resoldering was failing? Were there financial considerations that led to that?
The same questions apply to the lack of training. Was that truly because the manual implied such events could never happen on the Airbus 320 (an obviously erroneous assumption)? Or were there financial or other operational barriers to providing that training?
And what about the regulatory oversight of the airline industry in Indonesia? Was it an oversight that they did not require all airlines to provide “upset recovery” training for all pilots? Should they not have seen that one particular part had required 23 maintenance interventions?
Failure to learn from previous accidents or incidents
The similarities to the 2009 Air France Flight 447 crash and the 2009 crash of Continental Flight 3407 near Buffalo, New York are strikingly similar. In the former, ice crystals obstructed the aircraft’s pitot tubes, leading to inconsistencies between the displayed and actual airspeed measurements, and causing the autopilot to disconnect, after which the crew reacted incorrectly and ultimately led the aircraft to an aerodynamic stall from which they did not recover (Wikipedia 2015). In the latter accident (see our Patient Safety Tip of the Week “Learning from Tragedies. Part II”) the pilot also did the opposite of what he should have done when the plane went into an aerodynamic stall.
Lingo and abbreviations
In our Patient Safety Tip of the Week “Learning from Tragedies. Part II”) we noted the dizzying array of abbreviations used in the aviation industry. When one reads the investigation report of the AirAsia Flight QZ8501 crash one wonders how pilots could ever function in cockpits without confusing abbreviations and terms. Again, we think aviation clearly needs to have a “do not use” abbreviation list similar to what we use in healthcare (see our Patient Safety Tips of the Week for July 14, 2009 “Is Your “Do Not Use” Abbreviations List Adequate?” and December 22, 2015“The Alberta Abbreviation Safety Toolkit”).
We don’t pretend to be experts in design from a human factors perspective. But having a system with sticks/levers that make it counterintuitive to operate in an aerodynamic stall situation seems to us to be an obvious design flaw. And a system that allows two pilots to simultaneously use controls that may counterbalance each other? We’ll bet Don Norman, author of the classics “The Design of Everyday Things” and “The Design of Future Things” (see our November 6, 2007 Patient Safety Tip of the Week “Don Norman Does It Again!”) would never let that happen!
The second in command was flying
Perhaps it’s coincidence but in this crash, in the Air France Flight 447 crash, in the Asiana Flight 214 crash (see our January 7, 2014 Patient Safety Tip of the Week “Lessons from the Asiana Flight 214 Crash”) and others where there were aerodynamic stalls from which recovery failed, the plane was being flown by copilots or second-in-command pilots. That does not necessarily imply that these generally less experienced pilots are more likely to err. Remember, they are often flying those parts of a flight that are considered relatively safe (i.e. the “cruise” part). And we do understand the importance of allowing the copilots to get the hours of airtime experience.
But maybe we are also deluding ourselves and letting our guard down once we get into the “safe” part of a flight. Isn’t this a little like when the attending physician leaves one OR to begin a second case in another OR because the first case is now in the “safe” portion (see our November 10, 2015 Patient Safety Tip of the Week “Weighing in on Double-Booked Surgery”)?
Yes, almost every incident with serious harm, whether in healthcare or aviation, involves a combination of human error and system error. Many of the press reports on this accident seemed to vilify the pilots, using terms such as “unfathomable” to describe some of their actions. But the bottom line is that their actions are not really so “unfathomable” given that other pilots and copilots have made similar mistakes in similar circumstances. It took us many years to realize that giving fatal doses of concentrated potassium to patients was really a system problem rather than “unfathomable” actions of a few nurses left at the “sharp end”.
Interestingly, some of the other factors we have often seen contributing to such accidents (eg. fatigue, violation of the sterile cockpit rule, etc.) do not appear to have contributed to the current accident.
And the most important lesson? Just as in serious healthcare incidents, there was a cascade of errors and events with multiple contributing factors that led to the disaster. Prevention of almost any one of many factors might have prevented this crash. What if the airline had provided training for “level” high speed stalls? What if the sticks/levers had been designed so that both could not be used simultaneously and cancel each other out? What if terminology used was standardized and not ambiguous? What if the circuit board had simply been replaced rather than attempted to be repaired by resoldering? What if the pilots had discussed what would happen when the circuit breaker was removed and realized that autopilot would disengage? What if the actions of the pilots in the prior Air France or Buffalo crash were incorporated into training? What if the regulator mandated the airline to fix the recurrently faulty circuit board?
Hopefully, some of the lessons learned from the investigation of this crash may be used to help prevent other disasters, not only in aviation but also in healthcare or other industries.
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”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
December 17, 2013 “The Second Victim”
January 7, 2014 “Lessons from the Asiana Flight 214 Crash”
KNKT (KOMITE NASIONAL KESELAMATAN TRANSPORTASI). Aircraft Accident Investigation Report. PT. Indonesia Air Asia Airbus A320-216; PK-AXC. Karimata Strait. Coordinate 3°37’19”S - 109°42’41”E. Republic of Indonesia. 28 December 2014. KNKT 2015
Wikepedia. Air France Flight 447. Wikipedia accessed December 23, 2015
January 12, 2016
New Resources on Improving Safety of Healthcare IT
Though we’ve been writing about unintended consequences of healthcare IT since 2007 (see the list of prior columns at the end of today’s column), such have really attracted widespread attention in the last couple years. In our January 2013 What's New in the Patient Safety World column “More IT Unintended Consequences” we noted important contributions from the Institute of Medicine (IOM 2011) and the Pennsylvania Patient Safety Authority (Spannon 2012) addressing patient safety issues arising from EHR’s. And in 2012 the ONC (Office of the National Coordinator for Health IT) released its proposed its Health IT Patient Safety Action and Surveillance Plan (ONC 2012), designed to help provide necessary data through reporting adverse event for developers, providers, researchers and policymakers to improve the safety of health IT and make care safer.
In 2014 the Office of the National Coordinator for Health Information Technology issued the “SAFER” guides that identify recommended practices to optimize the safety and safe use of EHRs (ONC 2014). Then in 2015 The Joint Commission issued Sentinel Event Alert #54 on “Safe use of health information technology” (TJC 2015). Both drew attention to the many ways in which healthcare IT-related issues have been associated with adverse patient outcomes.
An excellent contribution on patient safety problems related to healthcare information technology (IT) was recently published (Graber 2015). Graber and colleagues culled 248 cases of malpractice claims related to healthcare IT from the large CRICO database over the period 2012-2014. Because this is a malpractice database the results are obviously biased towards cases with more serious adverse outcomes. So we cannot quantify the incidence of harm related to healthcare IT issues nor the overall likelihood of harm as a result of healthcare IT issues. Nevertheless, this study demonstrates that there are indeed cases of harm related to healthcare IT issues and has many valuable lessons.
To the 248 cases they applied their proprietary taxonomy of 15 sociotechnical category codes to determine which IT issue categories were most likely to be associated with malpractice claims. Not surprisingly, they found that cases spanned the categories and no one category stuck out as being most vulnerable. Rather the clinical context in which they occurred seemed to be more important.
Of the cases, 146 occurred in the ambulatory setting and the rest in inpatient or ER settings. Lumping them into 2 major categories of contributing factors, they found user-related issues accounted for 63% and system-related IT issues in 58% (many cases had contributing factors from both major categories). Medication-related issues (31%), diagnostic errors (28%), and errors related to treatment (31%) accounted for 90% of the claims. Over 80% of claims in all settings had harm of medium or high severity. Fatal outcomes occurred in 18% of the ambulatory claims and 39% in the ER or inpatient settings.
In the ambulatory setting one contributing factor category did stand out: issues related to hybrid record systems. That should not come as a surprise. In our July 2009 What's New in the Patient Safety World column “Failure to Inform Patients of Clinically Significant Outpatient Test Results” we noted a study (Casalino 2009) which showed those practices using a combination of paper and electronic records (so called “partial EMR”) had higher rates of failure to inform patients of abnormal test results than those having either a full EMR or full paper-based systems. Perhaps in the current Graber study this reflects the time when offices were just making the transition from paper-based systems to electronic medical records. But, as pointed out by the authors, it also likely means that future periods of transition (eg. system upgrades, changes to new IT systems, etc.) are also likely to be vulnerable periods.
The real value of the Graber study, however, comes from the case examples provided and the several recurrent themes they observed. We already alluded to the theme of hybrid medical records being especially vulnerable. A second theme relates to delays in diagnosis or treatment due to results or reports or actions that are missing, delayed, misdirected, or incorrect. While we all know how easily reports could get filed in the wrong patient chart in the paper-based world, misdirection of reports and other information also occurs in the EHR world. Graber and colleagues note that we need to better understand both the system- and user-related causes of misrouting errors. Several of our prior columns have addressed the issue of test results “slipping through the cracks”, resulting in delays or failure to diagnose and treat serious conditions. Most recently, in our November 17, 2015 Patient Safety Tip of the Week “Patient Perspectives on Communication of Test Results” we noted that any acceptable system for tracking followup on patient tests needs to do the following:
You’d think that today’s sophisticated EMR’s would have built in even better systems for tracking test results. But one big problem is still lack of interoperability among various systems. Many reports still arrive back at the office in paper format rather than an electronic format. Of course, we can scan those paper reports into most EMR’s. Don’t forget: paper-based reports always were vulnerable to the issue of two pages sticking together, often resulting in a report being filed in the chart of the wrong patient. And we’ve also pointed out the critical issue of test results coming back after a hospitalization or ER visit that never get back to the primary physician because of lack of interoperability (and lack of systems that ensure the hospital-based physicians follow up with the primary physician).
Another theme in the Graber study was that, largely because of cut-and-paste capabilities or ability to pre-populate data, incorrect information may be propagated in the medical record. For example, importing a previous medication list might include medications the patient is no longer taking. Or omission of a medication on a medication list may result in continued omission of that medication in the future. They also emphasized the well-known risks of overriding alerts and employing workarounds.
One overarching theme was overreliance on the EHR. We often assume that the information contained in it is both complete and accurate.
And lack of some functionality that should be expected of a computerized system is also a theme. Examples given are failure to identify decimal point errors that result in overdoses of medications, or failure to identify an inappropriate order for potassium in a patient already hyperkalemic.
The Graber study includes some design issues as well. As an example they note a complaint field in the EHR was too small to include the full complaint causing entry of “epigastric pain” rather than “sudden onset of chest pains with burning epigastric pain, some relief with antacid” in a patient who subsequently experienced a cardiac event.
Many of the issues addressed in the Graber study are reflected in a new guideline issued by the National Institute of Standards and Technology (NIST) for EHR standardization (Lowry 2015). That guideline identifies 3 critical use risk areas:
They note that lack of standardization may result in ordering or recording information in the wrong patient chart. Our Patient Safety Tips of the Week for May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?” and July 17, 2012 “More on Wrong-Patient CPOE” discussed many of the reasons such errors occur and noted some of the tools that have been used to minimize the chances of such occurring. However, standardization would be very important in helping prevent such errors. NIST also notes that information is often fragmented and stored in different locations in the EHR, leading to difficulty finding it. In addition, some information is verbal or on paper or white boards and does not get input into the EHR. Moreover, context is typically lacking. Navigation issues, scrolling issues, etc. also interfere with finding of information. Other issues include how to identify draft vs. final versions and how changes are made and identified as such. Unnecessary duplication of data input (eg. height and weight) was noted as an issue (though note our caveats in our December 8, 2015 Patient Safety Tip of the Week “Danger of Inaccurate Weights in Stroke Care”).
Two “use cases”, one for the inpatient setting and one for the outpatient setting, are provided in the NIST guideline for validation and usability testing.
The SAFER Guides (ONC 2014) also provide excellent recommendations regarding issues such as ensuring correct patient identification, test tracking and followup, CPOE and clinical decision support, communication, and several system and organizational issues. These come with checklist-style self-assessment tools and recommendations on how your organization can go about assessing and addressing these vulnerabilities. These are excellent tools.
The EHR and other computerized tools are clearly here to stay and offer tremendous potential to improve patient safety. We have yet to realize their full potential. Taking steps to correct the many unintended consequences we have seen will help us realize that potential. These resources and many we’ve described in our previous columns are a step in the right direction.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
Institute of Medicine (IOM). Health IT and Patient Safety: Building Safer Systems for Better Care. November 8, 2011
Spannon E, Marella WM. The Role of Electronic Health Record in Patient Safety Events. Pa Patient Saf Advis 2012; 9(4): 113-121
ONC (Office of the National Coordinator for Health Information Technology). Health IT Patient Safety Action and Surveillance Plan. December 21, 2012
ONC (Office of the National Coordinator for Health Information Technology). SAFER GUIDES—Safety Assurance Factors for EHR Resilience. 2014
The Joint Commission. Sentinel Event Alert #54. Safe use of health information technology. March 31, 2015
Graber ML, Siegal D, Riah H, et al. Electronic Health Record-Related Events in Medical Malpractice Claims. Journal of Patient Safety 2015; Published Ahead-of-Print November 6, 2015
Casalino LP, Dunham D, Chin MH et al. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Arch Intern Med. 2009; 169(12):1123-1129
Lowry SZ, Ramaiah M, Taylor S, et al. NISTIR 7804-1. Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization. National Institute of Standards and Technology 2015
January 19, 2016
Patient Identification in the Spotlight
In last week’s column (January 12, 2016 Patient Safety Tip of the Week “New Resources on Improving Safety of Healthcare IT”) we again mentioned the problem of entering data or orders on the wrong patient. Our Patient Safety Tips of the Week for May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?” and July 17, 2012 “More on Wrong-Patient CPOE” discussed many of the reasons such errors occur and noted some of the tools that have been used to minimize the chances of such occurring.
In that 2008 column we noted the following factors that contribute to wrong patient errors:
Remote order entry
First and foremost is the fact that with CPOE orders are often being entered remotely, that is not at the patient’s bedside. We previously cited examples of unintended consequences of remote order entry. ISMP had an example of a nonventilated patient inadvertently being given a paralytic agent. This occurred in part because the ordering physician was entering orders from a remote site and accidentally ordered this, not recognizing the patient was not ventilated (ISMP 2007).
One might argue that in the old paper-based system we also often enter orders remotely. We often take a chart from the patient chart rack in the nursing station and enter orders there. Certainly one could pick up the wrong chart and begin writing orders there. But there are several factors that probably make it more likely during CPOE and you need to address them during your CPOE implementation to minimize the risk of this unintended consequence. Below are 5 common scenarios that can lead to entering orders on the wrong patient via CPOE:
Patient name and other ID items not appearing on every screen
We’ve seen systems where navigation clicks or scrolling remove these critical identifiers from the screen. You need to ensure that the name and other identifiers remain anchored at the top of every screen of your CPOE system. (And remember to make your identifiers consistent with your Joint Commission compatible patient identification policy).
The cursor/stylus or juxtaposition error
The same error one sees with selecting a drug from a drop-down list obviously can also occur when selecting a patient from a drop-down list. Both are juxtaposition errors but we often call this a cursor error when it occurs while using a larger data entry device, and a stylus error when using a smartphone or tablet as an entry device. There errors are probably more common with the latter devices. There are no quick fixes for these, though thoughtful screen layouts can minimize the risk of these errors.
The “truncated scroll” syndrome and similar names
When searching for a specific patient, the results list may be longer than the current screen. The physician may simply pick the last name on the screen if it looks like the one he/she is looking for, failing to realize that there may be more patients with that name (he/she would have to continue scrolling the list to see them). You need to attempt to prevent your patient searches from “splitting” patients with like names in any screen window (or otherwise alert the user to scroll because there may be more similar names).
You would be surprised to see how often patients with the same or very similar names may be hospitalized at the same time. Shojania (Shojania 2003) described a near-miss related to patients having the same last name and noted that a survey on his medical service over a 3-month period showed patients with the same last names on 28% of the days. The problem is even more significant on neonatal units, where multiple births often lead to many patients with the same last name being hospitalized at the same time and medical record numbers being similar except for one digit. Gray et al. (Gray 2006) found multiple patients with the same last names on 34% of all NICU days during a full calendar year, and similar sounding names on 9.7% of days. When similar-appearing medical records numbers were also included, not a single day occurred where there was no risk for patient misidentification. Both these studies were on relatively small services so one can anticipate that the risks of similar names is much higher when the entire hospitalized patient population is in the database.
The dual system issue
Some CPOE systems that have limited integration with other systems, such as a radiology PACS system. It is not uncommon for a physician to look at information on that other system while trying to input orders into the CPOE system. Since they are two different systems, it is possible to be looking at two different patients in the two systems. You therefore need to ensure that when the physician moves between these two systems the same patient must be visible on each system. That means you need to develop a way to launch the other application and port the patient identification information to the other application.
The failure to log off issue
This occurs when a physician leaves the order entry screen temporarily without logging off and a second physician comes by and leaves orders on a patient (without logging on separately). The first physician then returns to the screen and assumes that he/she is still entering orders on the original patient.
The wrong patient error has been in the spotlight again recently. Green and Adelman, who have developed some of the excellent tools we’ve mentioned in previous columns, published an excellent example in a recent AHRQ Web M&M (Green 2016). This was an incident where a new receptionist, learning a new EHR, registered a patient who was new to the practice but had the same name and age as an existing patient in the practice (but different birth dates). The error was noted only when lab results were sent to the previously existing patient, who called the practice to note he had not had any labwork done. Green and Adelman note that wrong patient errors are actually more common in outpatients, being almost double the rate seen in the emergency department.
Green and Adelman stress the importance of training for anyone performing patient registration and note there are certification programs available.
In our July 17, 2012 “More on Wrong-Patient CPOE” discussed many of the reasons such errors occur and noted some of the tools developed by Adelman and colleagues to minimize the chances of such occurring (Adelman 2013). The intervention tools they developed were simple yet elegant. The “ID-verify alert” was triggered by opening an order entry screen and prompted the physician with the patient name, gender and age and the physician was required to acknowledge that was the correct patient before being allowed to proceed with order entry. The “ID-reentry function” prevents the provider from accessing the order entry screen until he/she re-enters the patient’s initials, gender and age. These interventions were piloted in a randomized fashion. While the “ID-verify alert” reduced errors by 16%, the “ID-reentry function” reduced them by 41%.
Patient photographs have been used in attempt to reduce the risk of wrong patient errors. Our June 26, 2012 Patient Safety Tip of the Week “Using Patient Photos to Reduce CPOE Errors”) highlighted an intervention developed by Children’s Hospital of Colorado (Hyman 2012) in which a patient verification prompt accompanied by photos of the patient reduced the frequency of wrong patient order entry errors. But photographs are not foolproof and need to be updated regularly. In the hospital setting, in particular, patients may be difficult to identify from prior photographs because of trauma, surgery, etc. We further discussed patient photographs in detail in our April 30, 2013 Patient Safety Tip of the Week “Photographic Identification to Prevent Errors”.
Biometrics are likely the next generation of patient identification tools (Davis 2016). These include not only fingerprints but things like retinal scans, iris patterns, palm patterns, vein patterns, etc. Those of you who have struggled unlocking your iPhones with your thumbprint will readily recognize that even these biometric techniques are not infallible. Facial recognition software is also evolving as another potential tool.
One added dimension to the problem of correct patient identification has to do with interoperability of IT systems. As patients get services at different hospitals, multiple labs, radiology practices, etc. multiple medical records are established with different identification numbers. As of yet we do not have a universal patient identifier. In lieu of such a universal identifier, various algorithms are used to attempt to match patients at one facility with the same patient at another facility in what is known as a master patient index or MPI. Algorithms may contain bits and pieces of a patient’s first and last names, social security number, date of birth, and other items to come up with an identification code that is very likely to identify the patient correctly at both facilities. However, such algorithms are not failsafe and misidentification does occur.
A recent survey of AHIMA health information professionals revealed that more than half of respondents noted they routinely have to try to mitigate against duplicate patient records (Dooling 2016). That same survey showed gaps in the quality improvement processes applying to registration or tracking such patient matching errors routinely. The barriers identified include: registration staff turnover, record matching/patient search terminology and/or algorithms, lack of resources to correct duplicates, inadequate information governance policy support, and lack of executive support. The authors note that reliable and accurate calculation of the duplicate rate is critical to reducing potential patient safety risks.
Both the Green and Adelman article and the AHIMA survey point out the importance of including those involved in patient registration in quality improvement and patient safety activities. A recent Canadian study (Campbell 2015) did a qualitative and observational evaluation of patient identification practices in the Pre-Admission Clinic, Admitting Department and the Perioperative Care Center and uncovered confusion, with 90% of patient verification occurrences not matching current policies. The authors conclude these discrepancies identify an opportunity to reassess and standardize workflow, clarify what identification methods are acceptable and determine additional appropriate identification verification practices with ID bracelets and patient charts.
Last week we also mentioned the SAFER guides from the Office of the National Coordinator for Health Information Technology (ONC 2014). One of the modules in the SAFER guides is on ensuring accurate patient identification. It includes both a checklist for organizational self-assessment and recommendations for improvement.
And, of course, not all solutions are high tech. In our August 2015 What's New in the Patient Safety World column “Newborn Name Confusion” we discussed another study by Adelman and colleagues in which they applied their “retract and reorder” (RAR) tool to assess the impact of a change in naming conventions for newborns (Adelman 2015). Hospitals need to create a name for each newborn promptly on delivery because the families often have not yet decided on a name for their baby. Most hospitals have used the nonspecific convention “Baby Boy” Jones or “Baby Girl” Jones. A suggested alternative uses a more specific naming convention. It uses the first name of the mother. For example, it might be “Wendysgirl Jones”. Montefiore Medical Center switched to this new naming convention in its 2 NICU’s in July 2013 and the RAR tool was used to measure the impact on wrong patient errors. Wrong patient error rates measured in the one year after implementation of the new more specific naming protocol were 36% fewer than in the year prior to implementation.
Patient misidentification and wrong patient orders or charting are significant threats to patient safety. We all need to be vigilant and track such errors as part of our regular quality improvement activities. We also need to learn from others and adopt best practices as they are discovered.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
ISMP (Institute for Safe Medication Practices). Remote CPOE error—a situation that’s more than remotely possible. ISMP Medication Safety Alert! Acute Care Edition. May 31, 2007
Shojania KG. AHRQ Web M&M Case and Commentary. Patient Mix-Up. February 2003
Gray JE, Suresh G, Ursprung R, Edwards WH, et al. Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 2006; 117: e43-e47
Green RA, Adelman J. New Patient Mistakenly Checked in as Another. AHRQ PSNet Web M&M 2016; January 2016
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc 2013; 20(2): 305-310 Published online 29 June 2012
Hyman D, Laire M, Redmond D, Kaplan DW. The Use of Patient Pictures and Verification Screens to Reduce Computerized Provider Order Entry Errors. Pediatrics 2012; 130: 1-9 Published online June 4, 2012 (10.1542/peds.2011-2984)
Davis J. Raymond Aller: Biometrics a crucial next step for patient safety. HealthcareITNews January 7, 2016
Dooling J, Fernandes L, Kirby A, et al. Survey: Patient Matching Problems Routine in Healthcare. Journal of AHIMA 2016; January 6, 2016
Campbell K, Muniak A, Rothwell S, et al. Improving Quality and Safety through Positive Patient Identification. Healthcare Quarterly 2015; 18(3): 56-60
ONC (Office of the National Coordinator for Health Information Technology). SAFER GUIDES—Safety Assurance Factors for EHR Resilience. 2014
Adelman J, Aschner J, Schechter C, et al. Use of Temporary Names for Newborns and Associated Risks. Pediatrics 2015; Published online July 13, 2015
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
In our June 2010 What's New in the Patient Safety World column “The Frailty Index and Surgical Outcomes” we noted a study by Makary and colleagues (Makary 2010) that showed frailty was associated with unwanted surgical outcomes. The Fried frailty index turned out to be very good in its ability to predict surgical outcomes. For instance, the odds ratio for frail patients for postoperative complications after major surgery was 2.54, for length of stay 1.69, and for discharge to a skilled nursing facility or assisted living facility 20.48. Odds ratios for those with intermediate frailty were somewhat lower but still predictive of all the above. And the frailty index was better than other tools used to predict outcomes (ASA score, Lee’s revised cardiac risk index, and the Eagle score). Adding the frailty index to any of those tools significantly improved the predictability of outcomes.
We’ve done multiple other columns (listed below) identifying studies that also show an association between frailty and surgical outcomes. Many used different methods for defining frailty, some using many more variables than those in the Fried index and others using only one or two variables. Some have shown that even just using limited measures of frailty, such as the timed up-and-go test or measuring grip strength, have the ability to predict surgical complications.
In fact, we consider assessment for frailty one of the three most important things that need to be done in a preoperative evaluation for potential surgery, the other two being assessment for obstructive sleep apnea and assessment for delirium risk (see our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change”).
Two new studies further illustrate the association between frailty and surgical morbidity and mortality. The first is a new population-based study which looked at the impact of frailty on mortality for a variety of major non-cardiac surgeries in over 200,000 patients age 65 and older in Ontario, Canada between 2002 and 2012 (McIsaac 2016). Frailty was determined from administrative data using the Johns Hopkins ACG frailty-defining diagnoses indicator. 3.1% of the population met the ACG frailty-defining diagnoses indicator. This group was older and had more comorbidities than the non-frail population. In the year following surgery 13.6% of frail patients died, compared to only 4.8% of non-frail patients. After adjustment for a number of variables, the 1-year mortality remained significantly higher (adjusted hazard ratio 2.23) in the frail population. Mortality was especially high in the early postoperative period (HR 35 on postop day #3 but then stabilizing between 2 and 3 by postop day 90). Though the hazard ratio decreased with increasing age, the association between frailty and mortality remained significant at all ages.
However, the relationship between frailty and mortality varied considerably by type of surgery. For example, the adjusted hazard ratio was not elevated for those undergoing pancreaticoduodenectomy or liver resection but was as high as 3.79 for those undergoing total hip replacement.
To differentiate the generally increased mortality of frail patients from that related to surgery, the researchers noted that the mortality diminished with time following surgery. That suggests that the stressors related to surgery were, in fact, major drivers.
Note also that it is quite likely there is already some bias in patient selection for the various types of surgery. But the results certainly suggest that individual risk:benefit analysis is important in the frail patient and consideration needs to be given to overall goals in this population when contemplating elective surgery.
The second study looked at the influence of frailty on complications of 21 common urological procedures (Suskind 2016). Data was from the ACS NSQIP database from 2007 to 2013. The frailty index used with this database does include impaired functional status but then adds a point for presence of or procedures/treatment for a number of comorbid conditions. They found that increasing frailty was associated with increasing odds of both minor and major complications and increasing frailty index scores were associated with increasing incidence of complications. This relationship held true for almost all the urological procedures included and was consistent across all age groups until the age of 81.
While we are not particularly fond of the frailty indices used in these two studies (we think they emphasize comorbidities much more so than patients’ abilities to function), they are available from administrative data and have been shown elsewhere to correlate with frailty.
Several studies have shown that much simpler tools may predict complications in elderly patients undergoing surgery. In our August 9, 2011 Patient Safety Tip of the Week “Frailty and the Surgical Patient” we noted two studies by Robinson and colleagues (Robinson 2009, Robinson 2011) looked at outcomes in (mostly male) patients age 65 and older who were undergoing major elective surgical procedures in the VA medical system and correlated them with measures of frailty, disability, and comorbidity. Using a group of markers that were easy to use in a surgeon’s office setting they were able to predict 6-month postoperative mortality and post-discharge institutionalization.
The evaluation for frailty need not be time consuming. Our September 3, 2013 Patient Safety Tip of the Week “Predicting Perioperative Complications: Slow and Simple” discussed studies showing how the time up-and-go test or tests of gait speed have a predictive value for frailty almost as good as more comprehensive evaluations. And our June 2015 What's New in the Patient Safety World column “Get a Grip on It!” cited a study (Revenig 2015) that showed the combination of “shrinking” (weight loss) and reduced grip strength alone held the same prognostic information as the full 5-component Fried Frailty Criteria for 30-day morbidity and mortality.
Like all the studies noted in our previous columns the new studies add to the evidence base demonstrating the tremendous vulnerability of the frail patient undergoing surgery or other procedures. That is why it is imperative that the pre-op or pre-procedure assessment of patients include assessment for frailty. If it is determined that a patient is frail, they need to be informed of the increased risks of the surgery/procedure, in the context that their life expectancy may also be limited in view of the frailty even without the surgery or procedure. Only then can the potential risks and benefits be discussed for that individual patient. The patient’s ultimate goals need to be considered in such decision making. The finding by McIsaac and colleagues of considerable variability by procedure type certainly needs further research but, as above, we think much of that is due to selection bias and we probably need to presume that the risks in the frail patient likely apply to all procedures.
And, while no study has demonstrated that any specific pre-op or pre-procedure preparation of the frail patient can minimize complications, the presence of frailty should make us increasingly vigilant for complications so they may be managed as early as possible. And the increased likelihood of discharge to a skilled nursing facility or assisted living center should be discussed with the patient prior to admission and planning for such contingencies be part of the care planning process from Day 1 or earlier.
Some of our prior columns on preoperative assessment and frailty:
Makary MA, Segeve DL, Pronovost PJ, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. Journal of the American College of Surgeons 2010; 210(6): 901-908
McIsaac DI, Bryson GL, Walraven C. Association of Frailty and 1-Year Postoperative Mortality Following Major Elective Noncardiac SurgeryA Population-Based Cohort Study. JAMA Surgery 2016; published online ahead of print January 20, 2016
Suskind AM, Walter LC, Jin C, et al. Impact of frailty on complications in patients undergoing common urological procedures: a study from the American College of Surgeons National Surgical Quality Improvement database. BJU International 2016; Published early online January 17, 2016
Robinson TN, Eiseman B, Wallace JI, et al. Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity. Annals of Surgery 2009; 250(3): 449-455, September 2009
Robinson TN, Wallace JI, Wu DS, et al. Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient. J Am Coll Surg 2011; 213(1): 37-42, July 2011
Revenig LM, Canter DJ, Kim S, et al. Report of a Simplified Frailty Score Predictive of Short-Term Postoperative Morbidity and Mortality. J Am Coll Surg 2015; 220(5): 904-911
February 2, 2016
Success Against Sepsis
Several recent published reports show that significant progress is being made in reducing mortality from sepsis. The SEPSIS KILLS quality improvement program in Australia showed a linear decrease in mortality from 19.3% in 2009–2011 to 14.1% in 2013 (Burrell 2016). There was also a significant decline in time in intensive care and total length of stay.
The SEPSIS KILLS program provides a sepsis toolkit with protocols for several settings (ED, ward) and pathways for several patient types (adult, pediatric, neonatal, maternal) and other resources, such as a page on escalation triggers. But basically it mirrors the core elements of the Surviving Sepsis Campaign. The key elements of SEPSIS KILLS are:
The focus of the program was on emergency departments. The program resulted in substantial increases in patients acutely triaged into either the “see immediately” or “see within 10 minutes” categories. The percentage of patients receiving antibiotics within 60 minutes of triage or recognition increased from 29.3% to 52.2%. And the percentage of patients receiving a second liter of intravenous fluid within one hour increased from 10.6% to 27.5%.
Some of the subset findings, however, were interesting. Mortality rates did not change significantly for those patients with high lactate levels (4 mmol/L or more) or those with what they termed “cryptic shock” (normotension but high lactate levels). But the group with hypotension and non-elevated lactate levels saw a decline in mortality rate from 16.5% to 9.8%. And the mortality rates for those with severe sepsis admitted to either the ICU or the ward did not change significantly over time. The authors actually noted it was bothersome that at the end of the study the mortality rates for those with severe sepsis admitted to wards was higher than for those admitted to ICU’s. They felt this might reflect an underappreciation of the potential mortality of sepsis. Also troubling was the fact that there was actually an increase over time in the mortality for patients with “uncomplicated” sepsis (3.7% to 6.7%).
The second publication was an article in Hospitals and Health Networks that summarized remarkable reductions in sepsis mortality in two multi-hospital systems (Butcher 2016). North Shore-Long Island Jewish Health System, partnering with the Institute for Healthcare Improvement (IHI), began a multidisciplinary program at its 15 hospitals aimed at sepsis in 2010 and achieved a 50% reduction in sepsis mortality by 2014. And Intermountain Healthcare, also with 15 hospitals, cut its sepsis mortality rate from 20.2% to less than 9% over a 6 year period.
Keys to success were re-engineering emergency department processes to screen for sepsis and administer early antibiotics and fluids to patients with sepsis and return serum lactate levels promptly to physicians so they could recognize cases of severe sepsis. The North Shore-LIJ program also attributed success to being widely inclusive of all parts of the organization in the planning process and ongoing (biweekly) conference calls where both progress and challenges were discussed.
Intermountain attributed their success to implementation of care bundles that achieved 80% compliance plus refinement of their data systems so that reporting was both more accurate and more real-time. They also were able to look at variations in performance across sites in their system to identify barriers and improve performance.
Prompt recognition of sepsis is the key because it obviously is the step necessary before early administration of antibiotics and fluid resuscitation. In our September 8, 2015 Patient Safety Tip of the Week “TREWScore for Early Recognition of Sepsis” we discussed the contributions made by early warning scores, such as the TREWScore (Henry 2015), that help identify sepsis or severe sepsis earlier. And in our October 2015 What's New in the Patient Safety World column “Even Earlier Recognition of Severe Sepsis” we noted a tool used by EMS personnel (Polito 2015) to help identify sepsis in patients before they even reach the hospital.
Early and adequate fluid resuscitation is a critical part of sepsis management. This has long been recognized but we think it inadvertently led to unintended barriers to sepsis care. Many of the early sepsis protocols called for a goal-directed therapy (EGDT) protocol, which included the invasive monitoring. We think many centers shied away from aggressive fluid management because of that requirement for central lines. But, fortunately, the randomized ProCESS trial (The ProCESS Investigators 2014) demonstrated that invasive monitoring did not improve outcomes (our April 1, 2014 Patient Safety Tip of the Week “Expensive Aspects of Sepsis Protocol Debunked”). Ever since our residency days we’d take great pride in showing our colleagues how a passive leg raise or equivalent can help with decisions about fluid/hemodynamic status in patients, avoiding the need for invasive monitoring.
The Australian study (Burrell 2016) also noted one particular challenge was educating a high turnover workforce in emergency departments and medical engagement in rural facilities. Our experience suggests this comment likely extends to the US as well. The physician staffing of rural ED’s often relies on physicians coming from substantial distances and staying only for one shift or only for several shifts. This makes it very difficult to ensure they have been updated when new or amended protocols have been put in place.
The Australian study also noted a major challenge in antibiotic prescribing. While the program did have a system-wide suggested empiric antibiotic guideline, each site was allowed to modify it. There seemed to be considerable anxiety over use of gentamycin. Also, the authors felt there might have been more timely revision of antibiotic regimens once lab reports became available.
Despite some of our concerns that the perceived improvements in sepsis morbidity and mortality over the last decade may actually have been artifacts due to changes in hospital coding practices (see our April 1, 2014 Patient Safety Tip of the Week “Expensive Aspects of Sepsis Protocol Debunked”), it appears that improvements in early recognition, timely antibiotics and adequate fluid resuscitation have indeed resulted in reduced mortality from sepsis.
Our other columns on sepsis:
Burrell AR, McLaws M-L, Fullick M, et al. SEPSIS KILLS: early intervention saves lives. Med J Aust 2016; 204(2): 1.e1-1.e7 February 1, 2016; Online first January 25, 2016
Clinical Excellence Commission (Australia). Sepsis Kills.
Surviving Sepsis Campaign. Website.
Butcher L. Stepping Up Against Sepsis. Hospitals & Health Networks 2016. January 13, 2016
Henry KE, Hager DN, Pronovost PJ, Saria S. A targeted real-time early warning score (TREWScore) for septic shock. Science Translational Medicine 2015; 299(7): 299ra122; 05 Aug 2015
Polito CC, Isakov A, Yancey AH, et al. Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool. Amer J Emerg Med 2015; 33(9): 1119–1125 Published online: April 22 2015
The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med 2014; 370(18): 1683-93 published online March 18, 2014
Print “Success Against Sepsis”
February 9, 2016
It was just a matter of time...
It was just a matter of time… In response to the serious problem of alarm fatigue across the nation, many hospitals have put in place sophisticated IT systems linking alarms to paging or messaging systems in attempt to get prompt responses by responsible staff to alarms. But a recent incident at a California hospital illustrates how wrong things can go in spite of (or because of) such systems.
The case (CDPH 2015) involved a patient with hypercarbic respiratory failure who was admitted to an ICU and put on a ventilator. As we see in most incidents resulting in patient harm, a series of events rather than a single event led to the untoward outcome.
The alarm management system at that hospital assigns a pager ID to a nurse and a respiratory therapist (RT) who have primary responsibility to respond to alarms/pages for each individual patient. But on the evening of the incident the patient expressed her desire to have a female respiratory therapist so the RT responsibilities were switched to another RT. But there was no change made in the alarm management system to indicate this switch in responsibility.
Around 3:00 AM a section of the patient’s ventilator circuit became disconnected from a Y-connector. Heart rate and oxygen alarms went off and a series of pages/messages were sent to an LVN (licensed vocational nurse) and an RT (respiratory therapist). Unfortunately, the RT with responsibility for the patient never received any such pages/messages and the RT to whom pages/messages were erroneously sent did not respond since he did not think he had any responsibility for this patient.
Though the patient’s room was only 13 feet from the nurses’ station and two nurses, including the charge nurse and the RN with primary responsibility for the patient, heard the loud audible alarm but none responded.
Statement from the RN with primary responsibility for the patient (who was at the nurses’ station and heard the audible alarm): “It was just the vent alarm, it’s not like it was the oxygen saturation alarm, so I didn’t think anything of it”. She saw the LVN go into the room. The LVN came out of the patient’s room and called the RN for help. They found the patient unresponsive and cyanotic and called the Rapid Response Team. Another respiratory therapist arrived with the Rapid Response Team and found the expiratory limb of the ventilator circuit had become disconnected from the Y-connector. It was determined that the ventilator had alarmed for 12 minutes due to oxygen desaturation before there was a response. The patient suffered anoxic brain damage and subsequently died.
The charge nurse, who was also at the nurses’ station, recalled hearing multiple alarms and did not respond to any because she was “distracted” by the report she was receiving from another nurse. The charge nurse did see the LVN enter the patient’s room and also recalled getting a phone call (just prior to the Rapid Response Team call) from the technician at the alarm center that was sending out the pages/messages stating that the patient was desaturating.
And there was another telling quote from the respiratory therapist to whom the alarm messages/pages were erroneously sent. While he denied receiving any pages at all, he said “It didn’t matter if I don’t get a page on that patient, the nurses get the pages too and they should have responded.”
Review of the central alarm system logs showed that 23 pages/messages had been sent to the RT who had not been assigned this patient and 24 were sent to the LVN. The pages had been sent because of both a rising heart rate and oxygen desaturation. In addition, the alarm center technician made 3 phone calls to the nurses’ station. The first was unanswered. The second was answered by the nurse with primary responsibility for the patient and she was told of the oxygen desaturation. The third was answered by the charge nurse who was informed of continued oxygen desaturation. The Rapid Response Team announcement went out shortly after that third call.
This unfortunate incident, of course, points out some of the key vulnerabilities of alarm management systems.
Firstly, it points out that the hi-tech systems are only as good as the data input to them. The computerized system appropriately sent out messages/pages to the personnel for whom it was programmed. But it was human error and system error that led to the failure to change the recipients after the change in assignment of RT responsibility had occurred.
Secondly, it points out blatantly what happens when more than one person is designated as responsible for the patient. Each assumes the other will respond and then no one responds. And even the nurses who were almost within arm’s length of this patient failed to respond because they expected someone else to respond. We’ve talked about this “dual responsibility” issue before. In our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks” we cited a paper (Singh et al 2009) on radiology reports that demonstrated dual alerts (those sent to both the referring physician and the primary care physician) were twice as likely to go unacknowledged. In the current case multiple parties all assumed someone else would respond.
There apparently was no system for escalation. A good system would escalate the messaging after a certain time elapses without a response from the individual with primary responsibility. In this incident the alarm system technician did escalate in that she made phone calls to the nurses’ station when the oxygen desaturation alarm continued. But apparently there was no formal escalation procedure in their policy and procedure for alarm management. Perhaps the system might have sent an initial page/message to the LVN, then a second page to both the LVN and RN if there was no response within 1 minute, and so on. The report also does not mention whether the RN who had primary responsibility for the patient was even in the messaging loop (the RN was paired with the LVN because of limited scope of practice for the LVN so both were responsible for the patient). Would it not have been appropriate for the system to escalate the pages/messages to that RN when others had not responded?
Note also it is not clear how this alarm management system recognizes whether someone has responded to the patient. Presumably the central technician would continue sending out pages/messages until the alarms stopped alarming. The technician would not know whether appropriate responders were already at the bedside attending to the patient.
The policies and procedures were deficient in that they did not clearly delegate responsibilities for responding to alarm messages/pages. Their policies and procedures for assignment of patient responsibilities was also deficient and there was no guidance for conveying changes in responsibility.
The hospital also had not been tracking response times as part of their quality improvement/patient safety monitoring. In our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” we noted one hospital found it took on average 9.5 minutes before a clinician responded to high priority alarms. Had the hospital in the current incident been tracking such response times before the event they might have identified and fixed problems in the system and avoided this unfortunate outcome.
We also wonder whether there was a knowledge deficit. The quoted comment above from the nurse who said it was only a ventilator alarm, not an oxygen desaturation alarm, probably had a poor understanding of respiratory physiology. This patient was admitted with hypercarbic respiratory failure. That means the patient might have progressive respiratory depression with hypercarbia which would occur before significant oxygen desaturation occurred, particularly if the patient was receiving supplemental oxygen. Perhaps other staff need re-education on all facets of hypercarbic respiratory failure as well.
How did the hospital respond?
1) They implemented daily ventilator alarm response drills
2) They implemented daily ventilator alarm checks
3) They developed a pager assignment verification process (each shift the supervisors for Respiratory Therapy and Nursing are to verify pager assignment for their respective staffs)
4) A multi-disciplinary Clinical Alarms Task Force was convened
5) A FMEA (Failure Modes and Effects Analysis) was completed
6) 3 individuals were terminated (see below)
7) Performance benchmarks were set for expected response times to ventilator alarms
8) Policy and procedure were revised to include “ventilator circuit connections shall be checked by staff after repositioning, bathing, and provision of care at the bedside”
9) The central alarm system policy and procedure was revised to include pager verification process steps to follow if they receive a page on a patient not assigned to them
10) Pager verifications to be reviewed daily
11) Several clinical indicators to be monitored were added including: staff response to ventilator alarms in <1 minute, pager assignment verification, internal ventilator alarm function test, and external ventilator alarm function test
The hospital’s Plan of Correction (POC) indicated that 3 individuals had been terminated (the RN and LVN with primary responsibility for this patient, and the RT to whom the alarm messages/pages had been erroneously sent). Should the 3 really have been fired? That is always a dual-edged sword. Who are the 3 individuals most likely to never make those mistakes again? Yes, the 3 individuals you just fired! And if during one of your ventilator alarm drills several other individuals do not respond promptly, would you fire them? We often make the mistake of taking one action based on the outcome of an incident and a different one when the outcome was benign even though the same mistakes were made in both circumstances. It may well be that other issues (eg. attitude, honesty, previous problems, etc.) played into their decision to terminate individuals. But it is very important to root out what was part of a problem with the safety culture of the unit as opposed to bad actions solely accountable to individuals. Could the same thing have happened had 3 different individuals been in those roles that evening? We obviously don’t know those answers. But there were certainly many upstream system defects that put those individuals in a position to make fatal errors.
There are several other considerations if you are using alarm management systems linking alarms to messaging/paging capabilities. One of these has to do with battery life. In our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” we recommended that 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. You also need to consider that there may well be “dead zones” in your facilities where transmission to a cell phone or other device may be blocked or otherwise unavailable. And you’ve never misplaced your smartphone even temporarily? Unlike anachronistic pagers that you kept attached to your belt except to look at what number to call, today’s smartphones or similar devices are typically used for much more than responding to pages/messages. The more frequently you remove that smartphone from its holster, the higher the likelihood that at some point you will put it down somewhere and lose it.
When we do RCA’s or review RCA’s we always also try to recognize things that were done well in addition to those not done well. In this case the hospital did several things well immediately after the incident:
So do we think such centralized alarm management systems linking alarms to messaging/paging capabilities are a bad idea? No. They have the potential to add valuable defenses in combating alarm fatigue. Yet the current incident provides many lessons learned that other hospitals need to consider:
And we refer you back to our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” for numerous other recommendations for your alarm management program.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
CDPH (California Department of Public Health). Statement of Deficiencies/Plan of Correction. CDPH Complaint Intake Number CA00397517. 2015
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586.
Print “It was just a matter of time…”
February 16, 2016
Fall Prevention Failing?
In our January 2016 What's New in the Patient Safety World column “HAC’s Have Declined Since 2010” we noted the reduction in overall hospital-acquired conditions that has occurred since 2010 as noted in a recent government report (AHRQ 2015). Notably, there was one salient HAC we did not comment on – falls. In fact, the reduction in falls between 2010 and 2014 was 0%. So there were no additional lives or dollars saved with respect to falls.
That is disheartening, given all the literature on fall risk assessments and various fall prevention interventions. On the other hand, it should not be surprising in view of the relative lack of strong evidence to show better patient outcomes resulting from these interventions.
A 2012 Cochrane review (Cameron 2012) concluded that limited evidence supports any one intervention and that more trials are needed to confirm the effectiveness of multifactorial interventions in the hospital setting. Another systematic review (Hempel 2013) also demonstrated the relative paucity of high quality evidence on fall prevention in acute care hospitals and pointed out many of the shortcomings in studies done. Frances Healey (Healey 2016), well-respected UK researcher on falls, has noted that high quality research on preventing falls in acute hospitals has been lacking and most studies showing a benefit of interventions have been at hospitals showing longer lengths of stay than we typically see in the US today (Oliver 2010).
In this regard, results of the recent 6-PACK fall prevention program (Barker 2016) in Australia are particularly disheartening. The 6-PACK program in Australia was a nurse-led targeted multifactorial intervention aimed at preventing falls and fall-related injuries in acute care hospitals. While previous studies had demonstrated multimodal fall prevention programs (some of which included elements of the 6-PACK but often including other elements) had reduced falls, the researchers felt that large scale randomized trials were needed to assess the robustness of the findings and generalizability. The 6-PACK program used a 9-item fall risk assessment tool and 6 specific interventions:
Randomization was done at the ward level rather than the patient level. The fall risk tool was updated at each shift by nurses and, if the patient was perceived to be at risk of falls, a “falls alert” sign was applied plus one or more of the remaining 6 intervention items. Patients on the “control” wards received usual care, which may have included some elements of the 6-PACK plus other interventions like no-slip socks and falls alert wristbands.
Use of all six 6-PACK interventions was three times more frequent on the intervention units. But despite the increased use of these fall prevention interventions, there was no improvement in either falls or fall-related injuries in the intervention group compared to the controls. It may well be that some of the chosen interventions (particularly the bed/chair alarms, low-low beds, and alert signs) have not had strong evidence in other studies.
Perhaps the real value of 6-PACK is that, in conjunction with a variety of other studies, it shows that we still have a long way to go in developing successful interventions to prevent falls and fall-related injuries. The study asks whether the considerable resources we now expend in acute care hospitals attempting to prevent falls might be better utilized on other patient safety issues.
The very insightful systematic review of fall prevention in acute care hospitals done a few years ago by Hempel and colleagues (Hempel 2013) noted that results of fall prevention interventions from long-term care settings may not apply to acute care settings because of increased acuity and short lengths of stay resulting in a greater burden on staffs. It then went on to review the quality and results of published studies on fall prevention interventions in acute care hospitals. Quite surprising was the overall poor quality of the studies (at least of what was reported in the studies) and the overall pooled analysis failed to show convincing results of interventions on patient outcomes. Almost all interventions targeted healthcare provider behavior rather than targeting patients directly. They noted several glaring shortcomings of many of the published studies. Most used multi-component interventions but many did not detail the individual components of those bundles. More than half used fall risk assessment tools that had not been validated. Very few included assessments of the adherence to the intervention components. And, perhaps most importantly, over half failed to note what fall prevention interventions were used in their control groups (either concurrent or historical comparators). While the majority of those published studies reported positive changes, there was considerable heterogeneity. They also noted that data on adherence to various strategies is also very relevant when it comes to the durability of the interventions over time.
In our October 27, 2015 Patient Safety Tip of the Week “Sentinel Event Alert on Falls and View from Across the Pond” we discussed The Joint Commission’s latest Sentinel Event Alert “Preventing falls and fall-related injuries in health care facilities” (The Joint Commission 2015) which quantified the magnitude of the problem in acute US hospitals, including the morbidity and mortality and cost associated with falls. The most common contributing factors identified by TJC from sentinel event reports are:
Lack of adherence to protocols and safety practices has been problematic elsewhere. We’ve previously noted a recent audit of hospital falls in the UK (Royal College of Physicians 2015) which often found a disparity between policies and practices. For example, only a fifth of patients were able to access their call bell and a third could not safely access their walking aid (if they used one). In addition, only 16% had their orthostatic vital signs assessed.
We have stressed over and over is that fall risk is not a static characteristic. Patients acutely hospitalized have changes in their status daily or even hour to hour. So a patient might lack fall risk factors on admission yet acquire them during his/her hospital stay. It is for that reason that the fall risk assessment must be done at least daily, if not on every shift. For example, a patient lucid on admission may have developed delirium. Or a medication that produces drowsiness and predisposes to falls may have been added. Or a drug that has orthostatic hypotension as a side effect may have been added. Or a drug with extrapyramidal side effects may have been started. Or changes in a patient’s fluid status (mobilization of fluid from third spaces, addition of a diuretic, etc.) may have begun and might be expected to increase the frequency of the need to void, keeping in mind that over half of all falls occur on toileting activities. Or a patient may have simply progressed from being confined to bed to beginning to ambulate.
One thing that has become clearer over the recent past is that fall risk prediction scores have little value. Rather, fall risk assessments should be used to identify risk factors specific to each individual patient and the focus should be on modifiable risk factors.
Fall prevention strategies aimed at the entire hospital population (eg. proper lighting, proper footwear, non-slip and non-trip surfaces, etc.) still have a role but there is little evidence that things like labeling patients as high risk for falls with alert signs, tags, wristbands, etc. really has done much to prevent falls. The following are the universal fall precautions from the AHRQ falls toolkit:
Our October 2015 What's New in the Patient Safety World column “Patient Perception of Fall Risk” noted a study showing that over half of patients deemed by nurses to be at high risk for falls did not themselves perceive their risk to be high and many did not fear injury from falling. So, of course, patient/family education is always considered part of fall prevention programs but don’t expect too much from that alone.
So, keeping in mind that the evidence for single interventions in preventing falls is scant at best, what are the interventions for fall risk factors specific to the individual patient?
For those with cognitive impairment or delirium:
If your screening identifies a patient with delirium, use of multi-component interventions like the Hospital Elder Life Program (HELP) for Prevention of Delirium program, as discussed in our multiple columns on delirium, should be considered. Use of sitters may be necessary. The AHRQ falls toolkit notes that some hospitals have cohorted patients with cognitive impairments into designated areas that have enhanced staffing to observe patients more closely. One hospital implemented this strategy using “safety zones” consisting of four patient rooms with one dedicated staff member responsible for those patients, who checks on the patients every 15 minutes. The hospital originally adopted this model as a less costly alternative to a patient sitter program and found it reduced fall rates and improved patient and family satisfaction.
For those with impaired gait or balance:
Any needed assistive devices, such as canes or walkers, should be at the bedside and within safe reach. Staff should inspect any such assistive devices the patient brought from home to make sure they are safe for use in the hospital environment. Even with assistive devices, patients may need help from staff for mobility. Also note our March 2015 What's New in the Patient Safety World column “Another Paradox: Falls Due to Walking Aids” noted sometimes such ambulatory assist devices may paradoxically increase the risk of falling. That may especially apply when they are used in an unfamiliar environment. The AHRQ falls toolkit has a nice algorithm for mobilization of patients.
For those with urinary frequency, urgency, or incontinence:
In our Patient Safety Tips of the Week for December 22, 2009 “Falls on Toileting Activities” and June 9, 2015 “Add This to Your Fall Risk Assessment” we noted that almost half of falls in hospitals occur during activities related to toileting, most occurring when attempting to go from bed or chair to the bathroom or returning from the bathroom rather than when getting on or off the toilet. And, not surprisingly, most of those falls occur at night. While poor lighting at night is a major contributor to falls, staffing levels during evenings and nights may also contribute. In our December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities” we noted a study showing that most falls related to toileting activities occurred in patients already labeled as being at high risk for falls (Tzeng 2010) and another study (Krauss et al 2008) showing poor staff compliance with toileting schedules, even during a period of a targeted intervention. (Interesting: that is at least the third time in this column we’ve mentioned poor adherence to or compliance with recommended practices as being problematic in preventing falls!) Though toileting need should always be assessed during nursing hourly rounds, we’ve also suggested that perhaps the toileting needs of our patients might be better met by aides or staff other than nursing. Perhaps a specially-trained aide or team could work from 10 PM to midnight or 9 PM to 11 PM and just focus on ensuring all patients at high risk for falls get appropriate assistance toileting before they go to sleep. Keep in mind that such attention to toileting is also important in the patient at risk for delirium. Note that we have also mentioned the gender issue on several occasions. Many studies have identified male sex as a risk factor for falls. We don’t know if that is due to macho vs. modesty. If it is the latter, then male patients may be hesitant to ask a female nurse to help them to the bathroom. So consider having some male aides on your “team” to assist male patients with toileting as well.
In our June 9, 2015 Patient Safety Tip of the Week “Add This to Your Fall Risk Assessment” we noted the following things you should be doing to reduce the risk of falls in your patients who have frequency, urgency or incontinence:
For those on high-risk medications for falls:
Get them off those medications if possible! Fall risk should be reassessed whenever medications are changed or a new medication is begun. Alerts during CPOE generated by a clinical decision support engine might be useful in this regard. Our experience is that physicians often ignore and override alerts like these unless they are presented with alternatives at the time of order entry. So consider sending the alerts instead to your pharmacists, who may be in a better position to contact the physician with their concern and suggest alternatives.
For those with orthostatic hypotension:
To review our annual harangue on how to properly assess patients for orthostatic hypotension see our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry”. Orthostatic hypotension in acutely hospitalized patients is often medication-induced (antidepressants, antipsychotic agents, antihypertensives, many cardiac medications, etc.) but may also be related to dehydration, volume depletion, and even “deconditioning”. Plus many diabetic patients with neuropathy may have some pre-existing orthostatic hypotension. So once you’ve identified orthostatic hypotension (and you have to look for it rather than waiting for a fall to trigger your doing orthostatic signs!) you need to review the medication list and see which medications you might eliminate or adjust. You also need to optimize fluid status. And you need to make sure all staff and family understand the patient is at risk when standing, so they don’t attempt to keep the patient upright when they shouldn’t.
For those with sensory deficits:
Notice we did not just say “those with vision problems”. As neurologists, we see the most common cause of dizziness and unsteadiness is actually the “multiple sensory deficit” syndrome. That’s where patients have impairment of vision, hearing, proprioception, and perhaps vestibular function, none of which should cause unsteadiness by itself but the cumulative effects lead to unsteadiness. So, yes, make sure your patients have their glasses but don’t neglect their hearing aids either.
For those with a history of frequent falls:
Obviously, in these patients you need to identify the reasons they fall and include the relevant interventions noted above. But some would also consider interventions such as low beds in these patients to minimize the risk of injury should they fall.
Wow! That’s a lot of recommendations for a topic for which we just said there is scant evidence of efficacy. Perhaps the key lessons from projects like the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool for Preventing Falls are that you need to have a robust data collection program regarding falls in place, do root cause analyses to identify the most frequent causes or contributing factors to falls at your facility, then implement those fall prevention interventions that address your most frequent causes and address individual-specific risk factors, monitor compliance/adherence related to those interventions, and track the outcomes.
Hopefully, some day we will get better evidence regarding which interventions actually make a difference in prevention of falls in the acute care setting.
Some of our prior columns related to falls:
AHRQ (Agency for Healthcare Research and Quality). Saving Lives and Saving Money: Hospital-Acquired Conditions Update. Interim Data from National Efforts To Make Care Safer, 2010-2014. AHRQ 2015
Cameron ID, Gillespie LD, Robertson MC et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2012; 12: CD005465. 23235623
Hempel S, Newberry S, Wang Z et al. Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. J Am Geriatr Soc 2013; 61: 483-494
Healey F. Preventing falls in hospitals (editorial). BMJ 2016; 352: i251 Published 26 January 2016
Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med 2010; 26: 645-692
Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ 2016; 352: h6781 (Published 26 January 2016)
The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert. 55: 1-5 September 28, 2015
Royal College of Physicians (UK). The Falls and Fragility Fracture Audit Programme (FFFAP) 2015. National audit of inpatient falls. Audit report 2015
AHRQ (Agency for Healthcare Research and Quality). Preventing Falls in Hospitals. A Toolkit for Improving Quality of Care.
Hospital Elder Life Program (HELP) for Prevention of Delirium
Tzeng H-M. Understanding the Prevalence of Inpatient Falls Associated With Toileting in Adult Acute Care Settings. Journal of Nursing Care Quality 2010; 25(1):22-30
Krauss MJ, Tutlam M, Costantinou E, et al. Intervention to Prevent Falls on the Medical Service in a Teaching Hospital. Infection Control and Hospital Epidemiology. Volume 29, Issue 6, Page 539–545, June 2008
Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool for Preventing Falls.
Print “Fall Prevention Failing?”
February 23, 2016
Weekend Effect Solutions?
The “weekend effect” (sometimes also known as the “after hours effect” since many of the same results apply to patients admitted at night as well as on weekends) in which increases in mortality, complications or adverse events are seen for patients admitted on weekends has been demonstrated for a wide range of both surgical and medical conditions. Our numerous previous columns on this issue are listed at the end of today’s column. Several more studies on the phenomenon have been published since our last column.
While the “weekend effect” has been demonstrated for a variety of medical conditions, it is not universal. One recent study showed that children admitted to Scottish hospitals on the weekend were not more likely to die than those admitted on weekdays (MNT 2015). Those admitted on weekends were even less likely to be readmitted than those admitted on weekdays.
But several other studies demonstrated the “weekend effect” for other conditions. A recent study from the UK (Robinson 2015) found that in-hospital cardiac arrests attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during weekday daytimes. The authors concluded that organizational or care differences at night and weekends, rather than patient case mix, appear to be responsible. Those results from the UK are quite similar to those from a study in the US (Peberdy 2008).
A recent large study in the UK (Palmer 2015) suggested that babies born at the weekend had an increased risk of being stillborn or dying in hospital within the first seven days and that there were also increases in the rates of other complications for both women admitted and babies born at weekends, with higher rates of puerperal infection, injury to neonate, and three day neonatal emergency readmissions. However, numerous rapid responses (rapid responses 2015) submitted after the publication have challenged the methodologies used in the study.
And yet another Scottish study demonstrated that stroke patients admitted on weeknights or weekends/holidays missed more guideline-recommended interventions and had higher mortality rates and fewer discharges to home (Turner 2016). Though those admitted on weeknights or weekends/holidays had comparable rates of early cerebral scanning and thrombolysis (after adjustments), they were less likely to receive swallow screening on the day of admission or be admitted to a stroke unit on day 0 or day 1. Mortality rates at 7 and 30 days were higher in those admitted on weekends.
And a paper presented at the American Society of Nephrology Kidney Week 2015 conference found that kidneys that would normally be made available for transplantation were less likely to be procured from donors over the weekend, and organs procured during the weekend were more likely to be discarded than kidneys procured on other days (ASN 2015).
One recent study suggested that specific hospital resources might be used to overcome the “weekend effect” seen in urgent general surgical procedures (Kothari 2015). Researchers identified emergent/urgent surgeries (appendectomies, cholecystectomies, and hernia repairs) in the HCUP database for Florida from 2007 to 2011 and used as a surrogate for the weekend effect an extended median length of stay on the weekend compared to weekdays. They identified 17 out of 166 hospitals that did not exhibit the “weekend effect” and looked to see how these hospitals differed from the others. Patient level factors like socioeconomic status did affect the occurrence of the weekend effect but hospital characteristics had more important associations with the weekend effect. They found that hospitals not having the weekend effect were more likely to have higher nurse-to-patient ratios, full adoption of electronic medical records, home health programs, pain management programs, and inpatient physical rehabilitation. The authors hypothesize that the improvement in the weekend effect at some hospitals is a result of “the ability of the identified components of perioperative infrastructure to assist patients with increased discharge needs, improve transitional care, and ensure care continuity from the week to the weekend”.
The study, of course, is limited by its use of administrative data and use of a proxy for the weekend effect. Also, the nurse staffing ratios were averages and did not specify whether such differed on weekends. Also questioned is why 3 procedures that typically have very low mortalities were chosen. Also, these are associations and may not play a causal role. But are they plausible contributory factors? They certainly could be. Previous work shows that the weekend effect is complex and involves both patient-related factors and quality of care factors (see our November 2013 What's New in the Patient Safety World column “The Weekend Effect: Not One Simple Answer”) While we may not be able to do much about the patient-related factors, there remains much we can do about the organizational and quality of care factors.
In our many previous columns on the weekend effect or after-hours effect we have pointed out how hospitals differ during these more vulnerable times. Staffing patterns (both in terms of volume and experience) are the most obvious difference but there are many others as well. Many diagnostic tests are not as readily available during these times. Physician and consultant availability may be different and cross-coverage by physicians who lack detailed knowledge about individual patients is common. You also see more verbal orders, which of course are error-prone, at night and on weekends.
We’ve often said the use of the simple nurse:patient staffing ratio on weekends may be misleading. That is because there is often a significant difference in nurse workload on weekends. We’ve described the tremendous increase in nurse responsibilities on weekends due to lack of other staff (no clerical staff, delayed imaging, physicians not on site) that add additional responsibilities to their jobs. Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” discussed how adding non-clinical administrative tasks to already overburdened nursing staff on weekends may be detrimental to patient care. Just do rounds on one of your med/surg floors or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing interruptions in some attention-critical nursing activities. Calls from radiology and the lab that might go directly to physicians now often go first to the nurse on the floor, who then has to try to track down the physician. They end up filing lab and radiology reports or faxing medication orders down to pharmacy, activities often done by clerical staff during daytime hours. Even in those facilities that have CPOE, nurses off-hours often end up entering those orders into the computer because the physicians are off-site and are phoning in verbal orders. You’ll also see nurses giving directions to the increased numbers of visitors typically seen on weekends. They may even end up doing some housekeeping chores and delivering food trays. All of these interruptions and distractions obviously interfere with nurses’ ability to attend to their clinically important tasks (see our Patient Safety Tips of the Week for August 25, 2009 “Interruptions, Distractions, Inattention…Oops!” and May 4, 2010 “More on the Impact of Interruptions”). We thus think that simply addressing nurse:patient staffing ratios without addressing nurse workload issues may be short-sighted.
It is clear we have not yet achieved the desired state in which our systems of hospital care are equivalent all hours of the day or all days of the week. Add to this the increase in acuity or severity for patient requiring weekend or after-hours admission and it is not surprising that we see less desrirable outcomes in those situations.
Some of our previous columns on the “weekend effect”:
MNT (Medical News Today). Patients not more likely to die at weekends, say researchers. Medical News Today 2015; November 27, 2015
Robinson EJ, Smith GB, Power SG, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study. BMJ Qual Saf 2015; Published online first December 11, 2015
Peberdy MA, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008; 299: 785-792
Palmer WL, Bottle A, Aylin P. Association between day of delivery and obstetric outcomes: observational study. BMJ 2015; 351: h5774 (Published 24 November 2015)
Turner M, Barber M, Dodds H, et al. Stroke Patients Admitted Within Normal Working Hours Are More Likely to Achieve Process Standards and to Have Better Outcomes. J Neurol Neurosurg Psychiatry 2016; 87(2): 138-143
ASN (American Society of Nephrology). Donor Organs May Be Discarded Due to “Weekend Effect” at Hospitals (press release). Newswise 2015; November 7, 2015
Kothari AN, Zapf MAC, Blackwell RH, et al. Components of Hospital Perioperative Infrastructure Can Overcome the Weekend Effect in Urgent General Surgery Procedures. Annals of Surgery 2015; 262(4): 683-691
Print “Weekend Effect Solutions?”
March 1, 2016
Several years ago we were trying to help a hospital find benchmarks for colonoscopy complications. We were amazed that such benchmarks were not readily available. We discussed complications of colonoscopy in our November 15, 2011 Patient Safety Tip of the Week “Rethinking Colonoscopy” and noted that the few studies done did not separate out screening colonoscopies from diagnostic or therapeutic ones. Rates also depend on whether polypectomy was done, and also relate to the age of the population and associated comorbidities (Warren 2009). All these factors make it extremely difficult to compare rates of colonoscopy complications across facilities. Some of the same factors likely explain why rates at free standing ambulatory sites tend to be lower than at hospital-based endoscopy units.
Researchers at the Yale-New Haven Center for Outcomes Research and Evaluation (CORE) also were recently struck by the paucity of readily available data on colonoscopy complications so they delved into the Medicare database to examine such (Ranasinghe 2016). Their primary outcome variable was any unplanned hospital visit within 7 days following the colonoscopy. Outpatient colonoscopies were followed by unplanned hospital visits within 7 days at an overall rate of 16.3/1000 colonoscopies, or a rate of about 1.6%. Hemorrhage, abdominal pain, and perforation were the most common causes of unplanned hospital visits.
They also note that very often the physicians performing the colonoscopies are unaware that any unplanned hospital visit occurred within 7 days after the procedure since they were often not informed of such by the hospital or patient.
The researchers then calculated a risk-adjusted measure of outpatient colonoscopy quality, which shows important variation in quality among outpatient facilities and might be used for both public reporting and quality improvement purposes.
The study did not break down the data by whether the colonoscopies included manipulation of any polyps, which we previously noted increases the risk of complications. We, thus, express concern that use of a measure that fails to take that into account might complicate interpretation of reports, whether used for public reporting or quality improvement purposes. We don’t want to hear the old chorus from our physicians “our patients are sicker” or “our population is different”.
Also the relationship of several of the reasons for unplanned hospital visits (eg. atrial fibrillation, chest pain, UTI, pneumonia) is unclear. Also, we wonder what the rate of unplanned hospital visit would be after almost any procedure. For example, in this population you might find such visits within 7 days of almost any procedure (eg. a dental procedure) or even within 7 days of a randomly chosen date! So it might be interesting to subtract such a “background” rate of unplanned hospital visits from the rate following colonoscopy.
In our November 15, 2011 Patient Safety Tip of the Week “Rethinking Colonoscopy” we cited statistics from the American Society of Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee (Fisher 2011) that the overall pooled rate of serious complications is on the order of 2.8 per 1000 colonoscopies. They noted that over 85% of the serious complications occur in patients undergoing colonoscopy with polypectomy performed. Rates of colonic perforation are generally below 1 per 1000 procedures and are probably closer to 1 per 10,000 for purely screening colonoscopies. Hemorrhage, immediate or delayed, occurs in 1 to 6 cases per 1000 colonoscopies and is more common in diagnostic colonoscopies and those with polypectomy. Polyp size and type are risk factors and patient comorbidities increase the risk of hemorrhage. It’s not clear whether the latter increases the risk or is just a marker for increased use of anticoagulants and antithrombotic agents. Other more serious complications such as death, infection, and colonic gas explosions are relatively rare. They also mention the postpolypectomy electrocoagulation syndrome, where a transmural burn gives rise to signs of localized peritonitis but is usually treated medically rather than surgically. Among less serious complications, they noted transient GI symptoms in as many as one third of all patients.
Complications may also arise from the sedation used during colonoscopy, though these are likely to occur during or shortly after the procedure rather than after discharge. Enhancing colonoscopy with the use of capnography has been suggested as a patient safety intervention. However, a new study demonstrates that for most patients undergoing colonoscopy with moderate sedation, the addition of capnography did not improve either complications or patient satisfaction but did increase costs (Barnett 2016). The authors compared 465 patients undergoing colonoscopy in the pre-capnography era with 501 patients in the post-capnography era. There were no serious adverse events in either group and minor adverse events occurred in 8.2% and 11.2% of patients in the pre- and post-capnography groups respectively. Levels of procedural discomfort were actually higher in the post-capnography era, as rated by both patients and nurses. Use of capnography added $11.68 per case. However, it is important to note that these patients were not considered high risk patients. Those considered high risk were already pre-selected to have their colonoscopies under deep sedation under the supervision of an anesthesiologist. We would certainly advocate for supervision by an anesthesiologist for patients with COPD or known obstructive sleep apnea (OSA). We’d also like to see screening for OSA with a tool like the STOP-Bang questionnaire (see our many columns on OSA) to identify further high risk individuals who might benefit from more intense monitoring.
And, almost as if on cue, the Canadian Task Force on Preventive Health Care just released its recommendations on screening for colorectal cancer in primary care and these do not recommend colonoscopy as the primary screening method for colorectal cancer (Canadian Task Force 2016). Instead, they recommend screening adults aged 50 to 74 years for colorectal cancer with fecal occult blood testing (guaiac fecal occult blood testing/gFOBT or fecal immunochemical testing/FIT) every two years or flexible sigmoidoscopy every 10 years. That recommendation is graded as “strong” for those aged 60-74 and “weak” for those aged 50-59, both based on moderate quality evidence. The Canadian Task Force actually recommends not using colonoscopy as a primary screening test for colorectal cancer. But that is given as a “weak” recommendation, noting the lack of randomized controlled trial evidence of efficacy and harms. It does note ongoing trials that may provide better evidence-based answers.
So why does the Canadian Task Force not agree with recommendations of the US Preventative Services Task Force (Whitlock 2008)? It’s not so much that they really disagree. It is more a matter of semantics and really boils down to strict adherence to the standards of evidence. Recommendations in the US regarding colonoscopy have been made based upon the fact that a similar endoscopic screening method – flexible sigmoidoscopy – reduces colorectal cancer mortality. And colonoscopy has largely become the de facto gold standard for colorectal cancer screening in the US.
The upcoming revision to the USPSTF recommendations (USPSTF 2015) is likely to be more in line with those of the Canadian Task Force. While the USPSTF acknowledges that there is no direct evidence that colonoscopy reduces colorectal cancer mortality, it again notes that a similar endoscopic screening method – flexible sigmoidoscopy – reduces colorectal cancer mortality. But it acknowledges that there has been no randomized controlled trial of colonoscopy to show a reduction in mortality (several are apparently in progress) and that there may be differences related to the two procedures. It does note that a prospective cohort study found an association between persons who self-reported being screened with colonoscopy and a lower colorectal cancer mortality rate (Nishihara 2013). That study looked at self-reported data from participants in the Nurses' Health Study and the Health Professionals Follow-up Study. It concluded that colonoscopy and sigmoidoscopy were associated with a reduced incidence of cancer of the distal colorectum; colonoscopy was also associated with a modest reduction in the incidence of proximal colon cancer. Screening colonoscopy and sigmoidoscopy were associated with reduced colorectal-cancer mortality but only colonoscopy was associated with reduced mortality from proximal colon cancer. Importantly, the USPSTF notes there are likely differences in harms between colonoscopy and flexible sigmoidoscopy, the latter having roughly ten times fewer complications (Whitlock 2008), so the net benefit of colonoscopy remains undetermined at this time.
Both the Canadian Task Force and the USPSTF agree that the most important thing is that some form of screening be done.
In that November 15, 2011 Patient Safety Tip of the Week “Rethinking Colonoscopy” we highlighted an editorial in the Journal of the National Cancer Institute that challenged the colorectal cancer screening strategy currently dominant in the US. Harris and Kinsinger in the editorial (Harris 2011) pointed out that there are randomized controlled trials that demonstrate that screening for colorectal cancer with fecal occult blood tests (FOBT) and flexibile sigmoidoscopy reduces mortality from colorectal cancer but they pointed out that evidence of the magnitude of additional benefit from colonoscopy is much less robust. Maybe it is only now that the rest of the medical world is taking a step back and saying we need to be truly evidence-based in our thinking. Perhaps the ongoing studies will answer the question better and find the proper place for colonoscopy in our screening armamentarium.
Warren J.L., Klabunde C.N., Mariotto A.B., et al: Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med 2009; 150: 849-857
Ranasinghe I, Parzynski CS, Searfoss R, et al. Differences in Colonoscopy Quality Among Facilities: Development of a Post-Colonoscopy Risk-Standardized Rate of Unplanned Hospital Visits. Gastroenterology 2016; 150(1): 103-113
Fisher DA, Maple JT, Ben-Menachem T, et al for the ASGE Standards of Practice Committee, Complications of colonoscopy. Gastrointestinal Endoscopy 2011; 74(4): 745-752
Barnett S, Hung A, Tsao R, et al. Capnographic Monitoring of Moderate Sedation During Low-Risk Screening Colonoscopy Does Not Improve Safety or Patient Satisfaction: A Prospective Cohort Study. The American Journal of Gastroenterology 2016; published online 2 February 2016
Canadian Task Force on Preventive Health Care. Recommendations on screening for colorectal cancer in primary care. CMAJ 2016; early release published February 22, 2016
Whitlock EP, Lin JS, Liles E, et al. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2008; 149: 638-658
USPSTF (U.S. Preventive Services Task Force). Topic Update in Progress. Colorectal Cancer: Screening. November 2015
Nishihara R, Wu K, Lochhead P, Morikawa T, Liao X, Qian ZR, et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med. 2013; 369(12): 1095-1105
Harris R, Kinsinger LS. Less is More: Not “Going the Distance” and Why.
JNCI 2011; 103(23): 1-3
Print “Colonoscopy Complications”
March 15, 2016
Dental Patient Safety
We were recently asked why we haven’t done any columns on dental patient safety. While over the years we’ve encountered a few minor safety issues in dental cases in hospitals, we’ve never looked at the broader issue of safety in dental practice where it is usually practiced – outside the hospital.
So here goes!
A report from Spain on patient safety in dentistry (Perea-Perez 2011) identified several reasons why patient safety has been less well addressed compared to medicine and surgery and we suspect the same issues apply in the US:
A recent systematic review found that the only interventions in dentistry that reduce or minimize adverse events are surgical safety checklists and highlighted the need for further research into patient safety in dentistry across several domains: epidemiological, conceptual understanding and patient and practitioner involvement (Bailey 2015).
A random sample from 20 dental practices in the Netherlands showed an overall 4.6% rate of adverse events, with 2.8% deemed preventable (Mettes 2013). The prevalence of preventable adverse events for all patient contacts was 0.13%. Potentially preventable adverse events included: retained root fragments, inadvertent removal of a permanent tooth, fractured instruments, excessive filling, swallowed partial prostheses, and removal of some teeth without prior X-ray. Of the 18 identified adverse events, 15 were classified as treatment-related, 10 as diagnosis-related, and one as communication-related. 37 causes were found for the 18 adverse events, 65% human and 30% organizational.
While we expected problems related to sedation would head the list of potential patient safety problems in dentistry, we found a whole host of reported safety issues:
Extracting the Wrong Tooth
Given the frequency with which we continue to see wrong site surgery in hospitals, it should not be surprising that extraction of the wrong tooth would occasionally occur. Indeed it does. The Doctors Company (a large medical malpractice insurer) notes it occurs with surprisingly high frequency and is, in most cases, preventable (The Doctors Company 2016a).
Prior to dental extractions there should be the same sort of timeout that we use prior to any surgery or procedure. That should include both a pre-procedure verification and then the timeout that immediately precedes the procedure. These include ensuring the correct patient, procedure, and correct tooth. Teeth have both a name and number so that should make correct identification easier, but errors still occur. Teeth may also shift when other teeth are missing, leading to confusion. And don’t forget to make sure there is a legitimate diagnosis that merits extraction of the tooth!
Copies of radiologic studies should be present (and correctly oriented) to help verification and the patient should be asked which tooth is the one to be extracted (though many patients with a toothache are not quite sure themselves which is the diseased tooth and others may have cognitive dysfunction that precludes self-identification of the tooth). The tooth to be extracted should be checked against the referral slip. There should be a dental diagram with the tooth/teeth for extraction clearly marked. Be especially aware when contiguous teeth are diseased.
Joint Commission’s Universal Protocol requires marking the site prior to surgery but one of the exceptions requiring alternative methods is teeth. It may be impractical to mark individual teeth. So prior to and during the timeout there is a need to indicate operative tooth name(s) on documentation and mark the operative tooth (teeth) on dental radiographs or dental diagrams and document. And the verification should be agreed upon by at least 2 people (the dentist or dental surgeon and a nurse or dental assistant).
Often when the wrong tooth is extracted, root cause analyses show multiple opportunities to have prevented the incident (Smith 2007). Smith notes common etiologies of wrong-site tooth extraction include cognitive failure and miscommunication, multiple contiguous carious teeth (rather than one identifiable diseased tooth), partially erupted teeth mimicking third molars, teeth with gross decay that the restorative dentist wants to save, reversed radiographs, and nebulous tooth numbering systems.
Complications of Sedation
Those of us who are baby boomers may recall much of our dental work was done under sedation with – ether! Now we look back and think how incredibly dangerous that probably was! We don’t recall being hooked up to any sort of monitoring devices (and they didn’t have pulse oximeters back then). We doubt the depth of sedation was closely monitored and bet that our protective reflexes were often rendered ineffective. And outpatient offices are probably not the greatest place to undertake full resuscitative measures if a sedation accident does occur.
In addition to the respiratory depression that may occur with sedation, loss of protective reflexes may predispose to aspiration or swallowing of crowns, teeth, instruments, gauze, etc.
Today dentists must be certified to do moderate sedation and go through at least as intensive training in sedation that we require for those physicians we credential and privilege to do moderate sedation in hospitals.
Yet incidents related to sedation continue to occur…
Deaths in patients who received sedation for dental procedures make the news every year (Otto 2014, AP 2015). Columns highlighting 8 (ABC News 2016) and 31 (Bradford 2012) respective deaths related to dental sedation provide some estimate of how frequently such complications of sedation occur. The most recent incident was just reported last week (George 2016). In this case a 4-year old girl suffered brain damage after receiving sedation for a dental procedure while being restrained by a device called a “papoose”. A CBS News report on this case (CBS News 2016) notes she was given multiple sedatives in the office for over seven hours for what was described as a routine dental procedure. Her heart rate was noted to be as high as 195 and her blood pressure to 168/77 and her oxygen saturation dropped as low as 49 percent. The “papoose” is a device confines the child's arms and legs so they can't interfere with the dental procedure. The CBS report notes that use of such devices for dental procedures in children is fairly widespread in the US and families and professionals need to be made aware of the dangers.
Another study, using primarily media reports, found 44 children who died subsequent to receiving anesthesia for a dental procedure in US dental offices, ambulatory surgery centers, and hospitals between 1980 and 2011 (Lee 2013). Most deaths occurred among 2–5 year-olds, in an office setting, and with a general/pediatric dentist as the anesthesia provider. In this latter group, 17 of 25 deaths were linked with a sedation anesthetic. That study likely significantly underestimates the number of serious complications from sedation and also did not include children who suffered neurologic injuries, suffered cardiac arrest, and were successfully resuscitated, or those who experienced respiratory arrest, but not cardiac arrest. The authors called for development of a national database for reporting both serious incidents related to dental sedation and near misses.
In a study of closed malpractice claims in pediatric dental patients 13 of 17 claims related to anesthesia involved sedation (Chicka 2012). The average patient age was 3.6 years and 6 involved the dentist as the anesthesia provider and the location was the dental office in 71% of cases. Only 1 claim related to sedation in which physiologic monitoring was used.
A prospective study of 51 patients needing dental treatment under oral conscious sedation found that postdischarge excessive somnolence, nausea, and emesis were frequent complications (Huang 2015). 60.1% of patients slept in the car on the way home and 21.4% of that group were difficult to awaken upon reaching home. At home, 76.1% of patients slept and 85.7% of patients who napped following the dental visit slept longer than usual.
Proper patient selection, adherence to proper sedation technique, appropriate monitoring, and prompt intervention are obviously important when using sedation in any setting. The American Dental Association has guidelines for the use of sedation and general anesthesia by dentists (ADA 2012) and most state health departments have requirements for dentists to be certified in the use of sedation in the office.
Swallowing crowns, whole teeth, instruments, etc.
It really shouldn’t be surprising that a patient might inadvertently swallow items during a dental procedure. The local anesthetics given not only numb the area being worked upon by the dentist or oral surgeon but also impair the ability of a patient to tell that there is a loose item in his/her mouth. Anyone who has undergone such procedures knows how easy it is to inadvertently swallow while the dentist or oral surgeon is working. Also, when sedation is used there may be a fine line between moderate sedation and deeper sedation where protective reflexes are impaired, making aspiration or swallowing items more likely.
During, for example root canal treatment, if the dentist places a rubber dam around the tooth during endodontic treatment then the risk of saliva contamination and ingestion of chemicals or aspiration of instruments is reduced. But there apparently is not a profession-wide consensus about the importance of rubber dam use (Gilbert 2015). Gilbert et al. suggest the patient safety aspect needs an effort similar to what has occurred in surgery regarding “never events”.
The Doctors Company recommends the following “if a patient inadvertently swallows part or all of a tooth, crown, or dental instrument, inform the patient immediately, and refer him or her for a chest or gastrointestinal x-ray. Any abnormal results should be reviewed by the patient’s physician, and a follow-up appointment with the physician should be scheduled. Document the dental record with any treatments provided and all discussions of the event, treatment options, and referrals for medical care. Coordinate arrangements with the patient and the treating medical practitioner for medical care and x-rays. Communicate with the patient’s physician and maintain a dialogue with the patient.” (The Doctors Company 2016b).
Failure to Use Antibiotic Prophylaxis
Failure to use antibiotic prophylaxis in patients with artificial heart valves or other foreign bodies that might become infected has been listed as a safety concern. However, most recent guidelines have actually done away with prophylaxis in many cases. Compared with previous recommendations, there are currently relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to certain dental procedures (ADA 2016). For example, for those with hip arthroplasties the current guidelines do not recommend antibiotic prophylaxis prior to dental surgery unless there have been complications related to the hip surgery.
A joint effort by the American Academy of Orthopedic Surgeons and the American Dental Association did a thorough review of the issue of antibiotic prophylaxis in patients with joint implants in 2012 (AAOS/ADA 2012) and came up with the following recommendations:
Recommendations now for antibiotic prophylaxis during dental procedures involve primarily patients at highest risk for infective endocarditis (eg. those with prosthetic valves, previous endocarditis, congenital heart disease, transplant patients with valvulopathy).
Bottom line: always check to ensure the most up-to-date guidelines for prophylaxis are followed.
Lingual Nerve Injury
Lingual nerve injury may complicate invasive dental and surgical therapies, resulting in numbness, dysesthesia, paresthesia, and dysgeusia (Graff-Radford 2003). The authors also note that unexplained nerve injury following dental procedures, especially tooth removal, may be caused by intraneural injection, creating permanent damage. They note that the incidence of lingual nerve injury consequent to surgery depends upon the procedure being performed, the surgeon's experience, procedure methodology, and certain patient-specific factors. Such injury is most common after mandibular third molar removal, the incidence of permanent nerve damage reported to vary between 0.5% and 2%.
A nice discussion of nerve injuries after dental injection cited the incidence from the literature as between 1 in 160,571 and 1 in 26,762 mandibular blocks (Smith 2006). Those authors note multiple potential mechanisms, including direct trauma from the injection needle, hematoma formation, and neurotoxicity of the local anesthetic.
Adverse Reactions to Local Anesthetics
Allergic reactions to local anesthetics can, of course, occur and may be unpredictable if there is no past history of such events. But other adverse reactions can occur to local anesthetics. Biron (Biron 2000) described toxic overdoses from local anesthetics in dentistry, which can be manifest by seizures or unconsciousness among other symptoms and signs. Such may occur from large amounts of local anesthetic injected, too rapid injections, inadvertent intravascular injection. And don’t forget that many of the local anesthetic preparations include vasoconstrictors that can cause adverse events in patients with underlying cardiac problems. The Biron article includes algorithms for management of toxic local anesthetic overdoses or reactions to vasoconstrictors.
Infection Control Issues
Potential contamination and transmission of pathogens is both a patient safety issue and a concern for staff safety. Concerns especially apply to potential transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), methicillin-resistant staphlycoccus aureus (MRSA) infection, among others (Klevens 2008).
The Doctors Company (The Doctors Company 2016b) has the following recommendations to reduce the chance of such transmission:
Details of cleaning and processing and sterilization of instruments is beyond the scope of today’s column but CDC has good resources regarding infection control issues in dental settings (CDC 2015) and for occupational exposures in dental settings (CDC 2013). Exposure incidents might place dental health care personnel at risk for hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV) infection, and therefore should be evaluated immediately following treatment of the exposure site by a qualified health care professional.
And, of course, dental offices as well as other venues performing dental or oral surgery procedures must have proper procedures for medical waste disposal.
Though patients may complain of pain and other symptoms of TMJ dysfunction following dental or oral surgery procedures, the evidence base linking the two is very scant. One study (Juhl 2009) was a prospective study to investigate if third molar surgery is associated with the development of symptoms and signs of temporomandibular disorders (TMD) during a 6-month post-operative observation period. In the patient group, they found: reduced range of maximum jaw opening at one week after surgery, increased characteristic pain intensity 1 week after surgery, increased disability up to 1 month after surgery, increased incidence of muscle pain on palpation up to 6 months after surgery, increased incidence of pain on palpation of the temporomandibular joint up to 6 months after surgery, and increased incidence of painful TMD 6 months after surgery. But, when compared with untreated controls, subjects undergoing third molar surgery have a statistically insignificant increased incidence of TMD 6 months post-operatively.
Failure to Address Significant Comorbidities
For example, excessive bleeding if you failed to note the patient was taking anticoagulants would be problematic. Similarly, using an agent to which the patient had a known allergy would also be problematic.
Patients of dentists are vulnerable to the gamut of medication errors that may occur when any physician or dentist prescribes drugs. See our many columns on medication safety.
Just as in any field of healthcare, diagnostic errors may occur in dentistry and oral surgery. In the Netherlands study noted above (Mettes 2013) many of the adverse events were noted to be diagnosis-related. Most often diagnostic errors might arise from failure to obtain appropriate dental radiographs prior to dental extractions. But there are other more complex symptoms that often masquerade as dental problems. We’ve often seen patients with atypical facial pain or even classic trigeminal neuralgia who have had dental procedures performed inappropriately for the pain before the patient ultimately sees a neurologist.
Rare adverse reactions
Some events that occur in other surgical settings might also be anticipated to occur rarely in dental practices. One such example might be latex allergy since patients might be allergic to latex in gloves of the dentist or hygienist or to the latex in a dental dam. Another theoretical event that might be precipitated by local anesthesia is malignant hyperthermia, though local anesthetics are said to be relatively safe in patients with known malignant hyperthermia by history. Nevertheless, it behooves all dentists and oral surgeons to be aware of the symptoms and signs of these rare events (latex allergy, malignant hyperthermia) since they require immediate interventions.
Dental Amalgam Issues
You are all familiar with the long-standing controversies over the relationship between dental amalgam and a variety of medical conditions. A review (Brownawell 2005) uncovered no convincing evidence pointing to any adverse health effects that are attributable to dental amalgam restorations besides hypersensitivity in some individuals.
Dentists, hygienists, and others are exposed to bodily fluids (saliva, blood) that put them at risk for contracting pathogens like hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and others. These can occur from needlesticks, bites, scalpel injuries, and perhaps even through aerosolization during drilling. Use of proper personal protective equipment is obviously the most important strategy to reduce the risks. But dental offices need to have protocols for dealing with such injuries, just as hospitals have.
Other potential staff risks include latex allergies and radiation exposure. While the radiation dose from typical dental x-rays is small, the cumulative dose over long periods could be significant. Therefore, it is crucial that all dental offices take appropriate steps to avoid radiation exposure.
In addition to the radiation exposure potential noted above, other radiology issues may occur. These might include use of equipment that provides suboptimal images, viewing images backwards, wrong-patient issues, and others that might lead to diagnostic or therapeutic errors.
Yes, we were surprised at the spectrum of patient safety events that may occur in the dental office or other venues where dental work or oral surgery are performed. It’s too bad there are no current ways to quantify the frequency of these various incidents. Nonetheless, simply being aware of the potential events and having systems in place to prevent such events or deal with such events when they do occur is important.
Perea-Perez B, Santiago-Saez A, Garcia-Marin F, et al. Patient safety in dentistry: Dental care risk management plan. Medicina Oral Patologia Oral Y Cirugia Bucal 2011; 16(6): E805-E809
Bailey E, Tickle M, Campbell S, O’Malley L. Systematic review of patient safety interventions in dentistry. BMC Oral Health 2015; 15: 152
Mettes T, Bruers J, van der Sanden W, Wensing M. Patient safety in dental care: A challenging quality issue? An exploratory cohort study. Acta Odontol Scand 2013; 71(6): 1588-1593
The Doctors Company. Preventing Wrong Tooth Extraction. Accessed February 26, 2016
Smith RA. AHRQ Web M&M. Mark My Tooth. Published July-August 2007
Otto M. Dentist under investigation after sedated child dies. Association of Health Care Journalists. January 13, 2014
AP (Associated Press). Dentist charged in death of patient getting 20 teeth pulled. FoxNews.com Published February 18, 2015
ABC News. Children in Danger at the Dentist. ABC News. Accessed March 7, 2016
Bradford H. Dental Sedation Responsible For At Least 31 Child Deaths Over 15 Years. Huffington Post 2012; July 13, 2012
George C. Mom says dental restraint device led to child's brain damage. Preschooler remains hospitalized, conscious, but unable to talk, get up. Houston Chronicle 2016; March 10, 2016 Updated: March 11, 2016
CBS News. 4-year-old girl suffers brain damage after dentist visit, family says.
CBS News March 14, 2016
Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Pediatric Anesthesia 2013; 23(8): 741-746
Chicka MC, Dembo JB, Mathu-Muju KR, et al. Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent 2012; 34(3): 231-238
Huang A, Tanbonliong T. Oral Sedation Postdischarge Adverse Events in Pediatric Dental Patients. Anesth Prog 2015; 62(3): 91-99
ADA (American Dental Association). Guidelines for the Use of Sedation and General Anesthesia by Dentists. 2012
Gilbert GH, Riley JL, Eleazer PD, et al. Discordance between presumed standard of care and actual clinical practice: the example of rubber dam use during root canal treatment in the National Dental Practice-Based Research Network. National Dental PBRN Collaborative Group. BMJ Open 2015; 5: 1
The Doctors Company. Patient Safety Challenges in General Dentistry. Accessed February 26, 2016
ADA (American Dental Association). Antibiotic Prophylaxis Prior to Dental Procedures. February 18, 2016
AAOS (American Academy of Orthopedic Surgeons) and ADA (American Dental Association). Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. Evidence-Based Guideline and Evidence Report. December 7, 2012
Graff-Radford SB, Evans RW. Lingual Nerve Injury. Headache 2003; 43(9): 975-983
Smith MH, Lung KE. Nerve Injuries after Dental Injection: A Review of the Literature. J Can Dent Assoc 2006; 72(6): 559-566
Biron CR. Adverse reactions to local anesthetics. RDH Magazine 1 Oct 2000
Klevens RM, Gorwitz RJ, Collins AS. Methicillin-Resistant Staphylococcus aureus. A Primer for Dentists. Journal of the American Dental Association 2008; 139(10): 1328-1337
CDC (Centers for Disease Control and Prevention) Infection Control in Dental Settings. Last updated September 18, 2015
CDC (Centers for Disease Control and Prevention) Frequently Asked Questions - Bloodborne Pathogens - Occupational Exposure. Last updated October 25, 2013
Juhl GI, Jensen TS, Norholt SE, Svensson P. Incidence of symptoms and signs of TMD following third molar surgery: a controlled, prospective study. Journal of Oral Rehabilitation 2009; 36(3): 199-209
Brownawell AM, Berent S, Brent RL, at al. The potential adverse health effects of dental amalgam. Toxicol Rev 2005; 24(1): 1-10
Print “Dental Patient Safety”
March 22, 2016
Radiology Communication Errors May Surprise You
We’ve done numerous columns on errors in communicating radiology results to physicians and patients (see the full list at the end of today’s column). A new study demonstrates frequent communication errors related to radiology (Siewert 2016). But the surprising finding was that the majority of those communication errors occurred at steps other than communication of test results! Results communication was still the single most common communication error but errors during ordering, scheduling, performance, and interpretation of a study were collectively more frequent.
The breakdown of communication errors was:
Mistakes could occur in written or verbal or electronic communication. Communication errors could occur between the radiologist and the ordering/referring physician or between the radiologist and the radiology technician.
In 37.9% of cases there was an impact on patient care, including major impacts (such as delayed recognition of malignancies or other serious conditions) in 23.4%. The authors also note that there was potential for patient impact in the majority of cases in which no actual impact was noted.
Communication errors also impact efficiency, leading to re-work in many cases, and patient inconvenience when studies need to be delayed or repeated. Communication errors may also lead to dissatisfaction on the parts of referring physicians and patients.
A recent review of radiology malpractice claims found such claims most commonly involve diagnosis-related allegations in the outpatient setting, particularly cancer diagnoses (Harvey 2016). But of interest in that study is that only 1.3% of claims involved communication failures as the primary allegation (plus an additional 4.6% as contributory factors in diagnostic-related allegations). That suggests that radiology practices are improving with respect to communication of significant test results.
Harvey and colleagues, however, do note another aspect of communication that may be a factor in malpractice claims. While they note that the preponderance of claims related to ambulatory settings may simply reflect the higher frequency of imaging in that setting, they also point out that the lack of IT integration may render the ambulatory setting more vulnerable than the inpatient setting. They note many studies have demonstrated that insufficient clinical data available to the radiologist increases the likelihood of a diagnostic “miss”. Whereas the institutional medical record may provide important collateral clinical information for the radiologist for inpatient cases, such data is often not available for many outpatients.
We empathize with radiologists who have suboptimal clinical information when interpreting imaging studies. In the era before electronic medical records that lack of clinical information was even more prevalent. We’d come across requisitions for abdominal imaging that simply gave “pneumonia” as the reason for referral. Many of the requisitions were, in fact, filled out by ward clerical staff after the physician wrote an order for the imaging study. Often the radiology technician or radiologist would have to ask the patient if they knew what the physicians were looking for and they often did not know or, worse yet, gave misleading reasons. A good radiologist would try to contact the ordering physician but that was not always practical or successful in a compressed timeframe. Today hospital radiologists usually have access to the electronic medical record if the patient is an inpatient or in a system where system-wide records are available. But many outpatient radiology practices have no such access to clinical information other than what was provided in the requisition.
We recommend you review a representative sample of your radiology requisitions. Pay particular attention to those requisitions that are transmitted through physician order entry systems. Many of those use drop-down lists or checkboxes in the field for “reason for study”. While such may promote ease of entry, they often lack sufficient detail for the interpreting radiologist that might be better served by additional free text information. Whether your requisition system is an electronic one or paper-based you may find you need to retool it to provide better communication from the referring physician to the radiologist. A good system also can improve efficiency (for example, might reduce the number of phone calls a scheduler or radiology tech has to make to clarify things like use of contrast, etc.). Good systems with clinical decision support tools also may help direct the ordering physician to the most appropriate study and avoid unnecessary imaging studies.
Good communication between the referring physician’s office and the radiology practice scheduling personnel can minimize the number of issues that arise. But the radiology staff are often distracted over details such as insurance coverage, etc. and may be less concerned about getting the necessary clinical information. Ironically, many of the “dreaded” third party systems contracted by insurers to pre-approve various high-end imaging studies may actually improve both clinical and administrative communication and may lead to improved efficiencies for a radiology practice.
One would also wonder how the frequent interruptions and distractions that affect a radiologist’s workflow might interfere with communication (see our July 1, 2014 Patient Safety Tip of the Week “Interruptions and Radiologists” and our November 2014 What's New in the Patient Safety World column “More Radiologist Interruptions”). While the studies we cited in those columns were primarily about interruptions occurring during overnight shifts in hospitals, such interruptions undoubtedly occur frequently even during daytime working hours in radiology departments or ambulatory radiology practices.
One patient safety tool we often utilize – the checklist – is probably underutilized in radiology practices. While some use checklists to help address all necessary components of radiology reports and checklists are often used for interventional radiology procedures, there is probably more opportunity for use of checklists for the more mundane day-to-day radiology procedures. Checklists are already widely used in MRI suites to ensure patients with ferromagnetic materials are not exposed to magnets. Schedulers can use checklists to ensure completeness of the requisition and coordination of any pre-study preparation with patients. Radiology techs can use checklists to ensure specific items are not overlooked prior to studies (eg. checking serum creatinine before studies involving intravascular contrast, checking to see if patient might be pregnant before some studies, etc.).
There are several types of communication error not really addressed in the Siewert study. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?”, among several of our other radiology suite safety columns listed below, we noted that many of the things that go wrong in the radiology department have little to do with radiology. The radiology suite just happens to be a location in which very sick patients with multiple ongoing interventions congregate temporarily. Adverse events like falls, medication errors, patient mixups, IV connection errors, running out of oxygen, conscious sedation incidents, suicides, and others may occur in the radiology suite and communication errors likely play a role in all of these. In particular, a “Ticket to Ride” type checklist is a valuable tool to promote communication of potential things that might go wrong while a patient is in the radiology suite. We refer you to the column above for a comprehensive discussion of what can go wrong in the radiology suite.
Radiology departments and ambulatory radiology practices should include audits in their monthly quality improvement activities to assess how often communication errors are occurring. You’ll probably find that the time invested in doing such audits is more than offset by the time savings you’ll see in improved efficiencies and better patient care. And while the studies cited in today’s column may indicate progress in communicating test results, look at our prior columns listed below for ensuring you have in place systems for failsafe communication of test results so that no patient “falls through the cracks”.
See also our other columns on communicating significant results:
And some of our other columns on interruptions and distractions affecting radiologists:
Some of our prior columns on patient safety issues in the radiology suite:
Siewert B, Brook OR, Hochman M, Eisenberg RL. Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency. American Journal of Roentgenology 2016; 206: 573-579
Harvey HB, Tomov E, Babayan A, et al. Radiology Malpractice Claims in the United States From 2008 to 2012: Characteristics and Implications. Journal of the American College of Radiology 2016; 13(2): 124-130
March 29, 2016
Inappropriate Lab Testing
A number of years ago we wanted to do a quality improvement project to reduce the number of lab tests ordered inappropriately. We knew the number was likely substantial since we’d see orders such as “daily electrolytes” or “CBC daily” written without consideration as to the likelihood they’d be abnormal. Somewhat surprisingly, the lab was not on board whole hog in doing such a project. Lab personnel pointed out that the cost of the reagents to perform the tests amounted to only pennies, some studies were less expensive to run as part of comprehensive profiles rather than individual tests, and that the expected savings was unlikely to be substantial. They may have been right – but only when considering lab costs. The true costs of inappropriate lab testing are downstream. It’s when the inappropriately ordered lab test leads to further tests and further unnecessary interventions that the costs begin to add up, both in fiscal terms and human terms.
We often state that about 30% of things we do in medicine are not necessary. When we used that estimate recently during an Osher Dartmouth adult learning course on patient safety one of the participants asked about unnecessary lab tests. So we went to the literature to get a more accurate picture of the scope of the problem. One literature review (Zhi 2013) looked at both over- and under-utilization of lab tests and found the mean rates were 20.6% and 44.8%, respectively. Interestingly, overutilization during initial testing was six times higher than during repeat testing (43.9% vs. 7.4%), a finding that was opposite of what was anticipated. Also, overutilization of low-volume tests was three times that of high-volume tests. Perhaps the most interesting finding, however, was the high rate of underutilization (i.e. tests indicated but not ordered). They do note that, however, that the research on underutilization is far less common. Zhi and colleagues point out that laboratory testing is the single highest-volume medical activity and drives clinical decision-making across medicine, with an estimated 4-5 billion tests performed in the United States each year. They note that overutilization can result in unnecessary blood draws and other sample-collection procedures and also increases the likelihood of false-positive results, which can lead to incorrect diagnoses, increased costs, and adverse outcomes due to unwarranted additional intervention. But they also note that underutilization can result in morbidity due to delayed or missed diagnoses and in downstream overutilization. Both over- and underutilization can both lead to longer hospital stays and contribute to legal liability.
Think about it – what are the real costs of unnecessary tests? Take serum bilirubin as an example. Suppose you order a bilirubin, perhaps as part of a “comprehensive chemistry profile” and the result is that it is modestly elevated. Perhaps the patient just has a benign condition like Gilbert’s syndrome and the result is of little consequence. But in many cases that result will lead to further tests looking for evidence of liver dysfunction or evidence of hemolysis. Further liver function tests might lead to imaging studies and even invasive procedures like liver biopsy. So you can readily see how the downstream costs of a test that was not originally indicated may cascade.
A study of the most commonly ordered laboratory tests on patients in a Brazilian ICU showed 49.4% of tests ordered had normal results (Oliveira 2014). On the other hand, 95.3% of the C-reactive protein tests had abnormal results (should that surprise you in an ICU population?). Applying criteria of appropriateness from the literature, those authors concluded that 41% of the tests ordered could be considered unnecessary. One interesting finding was that more tests were ordered on Mondays than any other day of the week. They cite a Canadian study (Cheng 2003) that had seen more tests ordered on Mondays and Fridays than other days of the week. Reasons for that trend were not discussed in the Brazilian study but the Canadian study suggested that postulated it to be due to a combination of attending physician unfamiliarity and defensive testing. We suspect it is more likely related to recognition that hospitals are not “business as usual” on weekends as we’ve discussed in our numerous columns on the “weekend effect”.
A number of studies have demonstrated that implementation of guidelines for ordering laboratory tests does result in reduced utilization of such tests. And greater use of IT capabilities has the potential to reduce inappropriate utilization of lab tests. Researchers at the Cleveland Clinic, after a pilot project, developed a clinical decision support tool (CDST) to block unnecessary duplicate test orders during the computerized physician order entry (CPOE) process (Procop 2014). They found the CDST blocked 11,790 unnecessary duplicate test orders over 2 years, which resulted in a cost savings of $183,586 and that did not even consider the potential cost savings from avoided downstream testing and procedures. There were also no untoward effects reported associated with this intervention.
One problem is that a patient may have had a lab (or radiology or other) test at a facility other than one that is part of your healthcare organization and, thus, results of that test are not available to the practitioner considering ordering the same test. Theoretically, as IT interoperability improves and we adopt health information interchanges (HIE’s), practitioners could have access to any recently done test and avoid unnecessarily ordering that same test again. However, one study that looked at the impact of HIE adoption found that even though there was a significant drop in laboratory tests ordered, imputed charges for laboratory tests did not shift downward significantly and for radiology testing, HIE adoption was not associated with significant changes in rates or imputed charges (Ross 2013).
When using IT solutions to reduce unnecessary lab tests we always have to keep in mind the problem of alert fatigue and reduce the number of disruptive alerts to a minimum. The Cleveland Clinic study (Procop 2014) was interesting in that regard. They had done pilot projects that allowed alerts to be overridden (“soft” alerts). One that was aimed at avoiding duplicate orders for expensive molecular genetics tests was successful but another that was aimed at avoiding more commonly ordered tests was not. So they ultimately decided to implement a clinical decision support tool that incorporated “hard” stops but was limited to a few key circumstances. For example they would identify instances where a test was ordered twice on the same day (an example they gave was when a test was ordered individually and also in a standard order set). They worked closely with their medical staffs to derive lists of tests that such alerts might be used for and tested such in small doses. Their final hard stop list consisted of 1,259 tests that would not be allowed more than once per day.
The Procop study provides an excellent example of how to implement clinical decision support tools successfully. There was crucial interaction with the medical staff at all phases of planning and implementation. They rolled out the tool for small numbers of tests before moving forward with the larger number of tests. They considered potential confounding events (eg. if an initial sample was not able to be used) and programmed in ways that the lab would enter this into the system so the alert would not trigger. And perhaps most importantly they did good auditing of the impact of alerts, looking for both physician complaints and untoward consequences.
There is a paucity of literature on the downstream costs of abnormal lab test results but we know they can be substantial. And unlike the growing literature on how to deal with unexpected findings on imaging studies (“incidentalomas”), there is a paucity of literature on how to best approach unexpected abnormal lab test results. One study (Lilford 2013) looked at patients with an abnormal result on an eight-panel liver function test (but no previously diagnosed liver disease). They found that repeating a complete panel in response to an abnormal reading is not the optimal strategy. They found that alanine aminotransferase (ALT) was associated with hepatocellular disease, while alkaline phosphatase (ALP) was associated with biliary disease and tumors of the hepatobiliary system. A restricted panel of ALT and ALP was an efficient choice of analytes, comparing favorably with the complete panel of eight analytes, provided that 48 false positives can be tolerated to obtain one additional true positive. More studies of this sort would be very useful.
We often make our patients jump through hoops and put them at risk when the result of a test that should not have been done in the first place comes back abnormal. Just as we are beginning to take closer looks at the net impact of certain screening tests (eg. PSA testing), it’s time we look at the net impact of doing some of the more mundane tests we order. Particularly as we move away from fee-for-service models and enter into more global budget or accountable care type models of reimbursement, it becomes important for hospitals and practices to become more aware of the impact of not only unnecessary imaging studies but also unnecessary or inappropriate lab tests.
Some of our other columns on errors related to laboratory studies:
Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis. PLOS One 2013; 8(11): e78962
Oliveira AM, Oliveira MV, Souza CL. Prevalence of unnecessary laboratory tests and related avoidable costs in intensive care unit. J Bras Patol Med Lab 2014; 50(6): 410-416
Cheng CK, Lee T, Cembrowski GS.. Temporal approach to hematological test usage in a major teaching hospital. Lab Hematol. 2003; 9(4): 207-213
Procop GW, Yerian LM, Wyllie R, et al. Duplicate laboratory test reduction using a clinical decision support tool. Am J Clin Pathol 2014; 141(5): 718-723
Ross SE, Radcliff TA, LeBlanc WG, et al. Effects of health information exchange adoption on ambulatory testing rates. JAMIA 2013; 20(6): 1137-1142 First published online: 1 November 2013
Lilford RJ, Behtham LM, Armstrong MJ, et al. What is the best strategy for investigating abnormal liver function tests in primary care? Implications from a prospective study. BMJ Open. 2013; 3(6): e003099. Published online 2013 Jun 11
Print “Inappropriate Lab Testing”
Click here to leave a comment on any of these tips.
To get "Patient Safety Tip of the Week"emailed to you, click here and enter "subscribe" in the subject field.
Click on the "Contact Us" button at the left to send us your comments on our "Patient Safety Tip of the Week" cases.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
April 25, 2017
April 18, 2017
April 11, 2017
April 4, 2017
March 28, 2017
March 21, 2017
March 14, 2017
March 7, 2017
February 28, 2017
February 21, 2017
February 14, 2017
February 7, 2017
January 31, 2017
January 24, 2017
January 17, 2017
January 10, 2017
January 3, 2017
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
December 13, 2016
December 6, 2016
November 29, 2016
November 22, 2016
November 15, 2016
November 8, 2016
November 1, 2016
October 25, 2016
October 18, 2016
October 11, 2016
October 4, 2016
September 27, 2016
September 20, 2016
September 13, 2016
September 6, 2016
August 30, 2016
August 23, 2016
August 16, 2016
August 9, 2016
August 2, 2016
July 26, 2016
July 19, 2016
July 12, 2016
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
June 21, 2016
June 14, 2016
June 7, 2016
May 31, 2016
May 24, 2016
May 17, 2016
May 10, 2016
May 3, 2016
April 26, 2016
April 19, 2016
April 12, 2016
April 5, 2016
March 29, 2016
March 22, 2016
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
January 19, 2016
January 12, 2016
January 5, 2016
December 29, 2015
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
October 27, 2015
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
September 29, 2015
September 22, 2015
The Cost of Being Rude
September 15, 2015
September 8, 2015
September 1, 2015
August 25, 2015
August 18, 2015
August 11, 2015
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
July 14, 2015
July 7, 2015
June 30, 2015
June 23, 2015
June 16, 2015
June 9, 2015
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
May 5, 2015
April 28, 2015
April 21, 2015
April 14, 2015
April 7, 2015
March 31, 2015
March 24, 2015
March 17, 2015
March 10, 2015
March 3, 2015
February 24, 2015
February 17, 2015
February 10, 2015
February 3, 2015
January 27, 2015
January 20, 2015
January 13, 2015
January 6, 2015
December 30, 2014
December 23, 2014
December 16, 2014
December 9, 2014
December 2, 2014
November 25, 2014
November 18, 2014
November 11, 2014
November 4, 2014
October 28, 2014
October 21, 2014
October 14, 2014
October 7, 2014
September 30, 2014
More on Deprescribing
September 23, 2014
September 16, 2014
Focus on Home Care
September 9, 2014
September 2, 2014
August 26, 2014
August 19, 2014
August 12, 2014
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
July 22, 2014
July 15, 2014
July 8, 2014
July 1, 2014
Interruptions and Radiologists
June 24, 2014
June 17, 2014
June 10, 2014
June 3, 2014
May 27, 2014
May 20, 2014
May 13, 2014
May 6, 2014
April 29, 2014
April 22, 2014
April 15, 2014
Specimen Identification Mixups
April 8, 2014
April 1, 2014
March 25, 2014
March 18, 2014
March 11, 2014
March 4, 2014
February 25, 2014
February 18, 2014
February 11, 2014
February 4, 2014
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
January 7, 2014
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
December 3, 2013
November 26, 2013
November 19, 2013
November 12, 2013
November 5, 2013
October 29, 2013
October 22, 2013
October 15, 2013
October 8, 2013
October 1, 2013
September 24, 2013
September 17, 2013
September 10, 2013
September 3, 2013
August 27 2013
August 20 2013
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
June 11, 2013
June 4, 2013
May 28, 2013
May 21, 2013
May 14, 2013
May 7, 2013
April 30, 2013
April 23, 2013
April 16, 2013
April 9, 2013
April 2, 2013
March 26, 2013
March 19, 2013
March 12, 2013
March 5, 2013
February 26, 2013
February 19, 2013
February 12, 2013
February 5, 2013
January 29, 2013
January 22, 2013
January 15, 2013
January 8, 2013
January 1, 2013
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
December 11, 2012
December 4, 2012
November 27, 2012
November 20, 2012
November 13, 2012
November 6, 2012
October 30, 2012
October 23, 2012
October 16, 2012
October 9, 2012
October 2, 2012
September 25, 2012
September 18, 2012
September 11, 2012
September 4, 2012
August 28, 2012
August 21, 2012
August 14, 2012
August 7, 2012
July 31, 2012
July 24, 2012
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
June 26, 2012
June 19, 2012
June 12, 2012
June 5, 2012
May 29, 2012
May 22, 2012
May 15, 2012
May 8, 2012
May 1, 2012
April 24, 2012
April 17, 2012
April 10, 2012
April 3, 2012
March 27, 2012
March 20, 2012
March 13, 2012
March 6, 2012
February 28, 2012
February 21, 2012
February 14, 2012
February 7, 2012
January 31, 2012
January 24, 2012
January 17, 2012
January 10, 2012
January 3, 2012
December 20, 2011
December 13, 2011
December 6, 2011
November 29, 2011
November 22, 2011
November 15, 2011
November 8, 2011
November 1, 2011
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
September 27, 2011
September 20, 2011
September 13, 2011
September 6, 2011
August 30, 2011
August 23, 2011
August 16, 2011
August 9, 2011
August 2, 2011
July 26, 2011
July 19, 2011
July 12, 2011
July 5, 2011
June 28, 2011
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
May 24, 2011
May 17, 2011
May 10, 2011
May 3, 2011
April 26, 2011
April 19, 2011
April 12, 2011
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
March 15, 2011
March 8, 2011
March 1, 2011
February 22, 2011
February 15, 2011
February 8, 2011
February 1, 2011
January 25, 2011
January 18, 2011
January 11, 2011
January 4, 2011
December 28, 2010
December 21, 2010
December 14, 2010
December 6, 2010
November 30, 2010
November 23, 2010
November 16, 2010
November 9, 2010
November 2, 2010
October 26, 2010
October 19, 2010
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
September 7, 2010
August 31, 2010
August 24, 2010
August 17, 2010
August 10, 2010
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
July 20, 2010
July 13, 2010
July 6, 2010
June 29, 2010
June 22, 2010
June 15, 2010
June 8, 2010
June 1, 2010
May 25, 2010
May 18, 2010
May 11, 2010
May 4, 2010
April 27, 2010
April 20, 2010
April 13, 2010
April 6, 2010
March 30, 2010
March 23, 2010
March 16, 2010
March 9, 2010
March 2, 2010
February 23, 2010
February 16, 2010
February 9, 2010
February 2, 2010
January 26, 2010
January 19, 2010
January 12, 2010
January 5, 2010
December 29, 2009
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
November 24, 2009
November 17, 2009
November 10, 2009
November 3, 2009
October 27, 2009
October 20, 2009
October 13, 2009
October 6, 2009
September 29, 2009
September 22, 2009
September 15, 2009
September 8, 2009
September 1, 2009
August 25, 2009
August 18, 2009
August 11, 2009
August 4, 2009
July 28, 2009
July 21, 2009
July 14, 2009
July 7, 2009
June 30, 2009
June 23, 2009
June 16, 2009
June 9, 2009
June 2, 2009
May 26, 2009
May 19, 2009
May 12, 2009
May 5, 2009
April 28, 2009
April 21, 2009
April 14, 2009
April 7, 2009
March 31, 2009
March 24, 2009
March 17, 2009
March 10, 2009
March 3, 2009
February 24, 2009
February 17, 2009
February 10, 2009
February 3, 2009
January 27, 2009
January 20, 2009
January 13, 2009
January 6, 2009
December 30, 2008
December 23, 2008
December 16, 2008
December 9, 2008
December 2, 2008
November 25, 2008
November 18, 2008
November 11, 2008
November 4, 2008
October 28, 2008
October 21, 2008
October 14, 2008
October 7, 2008
September 30, 2008
September 23, 2008
September 16, 2008
September 9, 2008
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
August 5, 2008
July 29, 2008
July 22, 2008
July 15, 2008
July 8, 2008
July 1, 2008
June 24, 2008
June 17, 2008
June 10, 2008
June 3, 2008
May 6, 2008
April 29, 2008
April 22, 2008
April 15, 2008
April 8, 2008
April 1, 2008
March 25, 2008
March 18, 2008
March 11, 2008
March 4, 2008
February 26, 2008
February 19, 2008
February 12, 2008
February 5, 2008
January 29, 2008
January 22, 2008
January 15, 2008
January 8, 2008
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
December 4, 2007
November 20, 2007
November 13, 2007
November 6, 2007
October 30, 2007
October 23, 2007
October 16, 2007
October 9, 2007
October 2, 2007
September 25, 2007
September 18, 2007
September 11, 2007
September 4, 2007
August 28, 2007
August 21, 2007
August 14, 2007
August 7, 2007
July 31, 2007
July 24, 2007
July 17, 2007
July 10, 2007
July 3, 2007
June 26, 2007
June 19, 2007
June 12, 2007
June 5, 2007
May 29, 2007
May 22, 2007
May 15, 2007
May 8, 2007
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
April 2, 2007
March 26, 2007
March 19, 2007
March 12, 2007
March 5, 2007
February 26, 2007