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October 5, 2010
More Iatrogenic Burns
Our June 1, 2010 Patient Safety Tip of the Week Iatrogenic Burns gave lots of examples of burns occurring as a result of encounters in various parts of the healthcare system. Since then a couple more examples have appeared in the literature or the news. One, in which flash sterilization of an arm positioning device led to a burn, is being litigated. The others are the subject of a recent FDA warning about burns occurring to dental patients as a result of electric dental handpieces overheating.
The first case, related to flash sterilization, is a theme we have seen before. In our June 1, 2010 Patient Safety Tip of the Week Iatrogenic Burns one or our recommendations was In the OR, beware of the burn danger any time a flashed piece of equipment is used. According to the article in Outpatient Surgery, a nurse preparing for a wrist surgery case found that the metal wrist traction tower needed to be sterilized. About an hour before the surgery the device was flash sterilized and brought to the OR to cool. The patient was under general anesthesia when her arm was positioned in the device. After the surgery third-degree burns were noted on the patients arm and back (which apparently had also been in contact with the metal tower). Further medical treatment, including skin grafting, was necessary. In a deposition, the surgeon testified that neither he nor the nurse assisting him noted any residual heat from the recently sterilized device.
There are several important lessons in this case. The important point made previously is that even moderate heat applied for a long duration is capable of producing burns and patients may be surprisingly unaware that the burn is occurring even if they are conscious. The potential damage to skin (or other organs) is a function of both temperature and duration. Note that in a previously reported burn related to flashed equipment (Rutala 1999) it was noted that the nurse was able to hold the instrument in her hand, though it felt warm but the more prolonged contact with the patient produced a burn. A second consideration is whether flash sterilization produces uniform temperatures thoughout the device being sterilized. In our previous column we noted that microwaved objects are particularly dangerous because heating with microwaves is not uniform. We dont know if the same issue of non-uniform heating might occur with flash sterilization. And, obviously, one of the most important factors is that the patient was under general anesthesia and could not perceive pain (or was incapable of responding even if she could feel pain).
Given the risk that flash sterilized instruments and devices have for producing burns, there ought to be a protocol for accurate measurement of temperature before such devices are used on patients (or inadvertently set down on the drapes overlying a patient). Even just feeling them to touch is probably not good enough because one would be expected to have on sterile gloves, which might impair ones ability to perceive excessive heat. We reviewed dozens of articles on flash sterilization and could find no such protocol for assessing whether the flashed device is safe from a burn perspective. They had lots of complex logs looking at all sorts of parameters for the actual strerilization procedure but none for assessing the burn safety aspect. The closest we came was a general statement that hot, wet instruments present a burn risk to both patient and OR staff and that they should be allowed to cool adequately before use. The CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 quotes the previously mentioned Rutala paper (Rutala 1999) patient burns may be prevented by either air-cooling the instruments or immersion in sterile liquid (eg. saline) but neither offer any actual parameters for safe use. Wed like to hear from any of you that have put protocols in place for formal temperature measurement of flashed equipment and see how youve done this. Otherwise wed have to look to the device manufacturing industry for guidelines.
Best way to avoid patient burns from flashed equipment: plan your cases better so that you have all necessary equipment ready and available well in advance so you have no need to flash equipment. Well bet that root cause analyses on 90% of these flash-related burns discovered that the piece of equipment in question could or should have been available. Yes, there are emergency circumstances where you may need to flash equipment but the majority of cases are flashing equipment that should have been available.
The second example comes from a just-issued warning from the FDA on patient burns from electric dental handpieces. In fact, this is not a first warning. Rather is a restatement of a prior warning issued in 2007. Re-issuing the warning is the result of the FDA receiving numerous more reports of such injuries. And though most cases involve dental patients, the same sorts of injuries may be seen with rotary surgical handpieces used in orthopedic surgery. The dental devices are electric dental handpieces and electric oral bone-cutting handpieces that are AC powered hand-held devices. The burns occur because (1) the patient is under local anesthesia (perhaps sometimes even conscious sedation) and cannot feel pain and (2) the dentist cannot feel the heat because there is an insulated handpiece housing around the heated attachment.
The FDA makes the following recommendations:
The FDA has also requested device manufacturers take the following actions:
While training and labels might help, such are considered weak solutions and we think there must be a stronger solution. An overheating alarm would be a step in the right direction but how about just designing the devices with a feedback mechanism that shuts the device off when it overheats? The 2007 warning mentioned that air-driven handpieces typically slow down when problems arise, thus alerting the operator to the problem. But the electric devices actually increase power to the handpiece when problems arise, leading to rapid heat buildup and there is no obvious change that provides feedback to the operator.
Anesthesia, whether local or regional or general, may predispose patients to burns. Even under general anesthesia, where a patient cannot respond, we wonder if there are subtle signs such as changes in heart rate, perhaps mediated reflexly at lower levels, that could alert the surgical team to a potential burn. We must remain ever vigilant for complications such as iatrogenic burns in patients we have rendered incapable of protecting themselves during procedures.
Woman Burned by Sterilized Positioning Device Sues Doc, Hospital. OutpatientSurgery.net September 2010
Rutala WA, Weber DJ, Chappell KJ. Patient injury from flash-sterilized instruments. Infect. Control Hosp. Epidemiol. 1999; 20: 458
CDC. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
Safety Investigation of Patient Burns Associated with Electric Dental Handpieces and Electric Oral Bone-cutting Handpieces
Date issued: Sept 23, 2010
FDA. Safety Alerts for Human Medical Devices. Electric Dental Handpieces and Electric Oral Bone-cutting Handpieces: Safety Investigation of Patient Burns.
FDA Public Health Notification: Patient Burns from Electric Dental Handpieces
Issued : December 12, 2007
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October 12, 2010
Slowing Down in the OR
No, this is not an article on how to spot surgeons on your staff whose skills have begun to decline! Rather, it is a summary of a recently published paper (Moulton 2010a) in the human factors engineering field that focuses on how skilled surgeons refocus their attention at critical times during surgical procedures. And we think that their findings also have some very important lessons from a systems perspective and implications for everyone in the OR.
The authors address (and in this case actually challenge) the premise that experts are able to do much of what they do while they are in automatic modes. That is, they tend to be able to perform many tasks and sub-tasks without giving much conscious thought to them. Rather, many of those processes are being handled at a subconscious level in the brain. But, obviously, any expert needs to be able to pop out of that automatic mode when necessary to take actions when circumstances change or unexpected events take place. So the authors looked at how highly respected surgons handle this transition from autopilot to a more focused cognitively effortful state. The authors consider this slowing down as the key factor that keeps surgeons from getting into trouble in cases and avoiding complications, adverse events, and near-misses.
The authors selected for their study surgeons at four Canadian academic medical centers who had reputations for having excellent surgical judgment. They conducted one-hour semi-structured interviews with 28 surgeons and further interviews with 8 of those surgeons. They then did direct observation in the OR of 5 hepatobiliary surgeons performing a total of 29 cases.
They found that the responses of surgeons were grouped into four categories on a continuum ranging from stopping (the most extreme response) to fine-tuning (the most subtle response). Responses in between were removing distractions and focusing more intently. They point out, however, that one does not really transition through each of these responses.
Stopping was the most extreme category. Here the surgeon would temporarily bring the procedure to a halt at a critical moment. Sometimes this stopping was actually planned ahead of time and was simply acknowledgement that a critical phase of the operation had been reached and the stopping was to ensure that all the staff were ready to proceed and that all resources were available for the next critical phase. In others the stopping occurred at a point of uncertainty and the surgeon might stop and look at the patients record or images or ask a colleague for assistance. In that type of stopping, use of words like regroup and reassess were often used.
Removing distractions was when, upon encountering a slowing down moment, the surgeon might become irritated and distracted by external stimuli. He/she might tell others in the OR to remove the distractions so that he/she could focus better on the issue at hand. The authors note that sometimes other OR team members might recognize the need for removing distractions but not always. They quote one surgeon as saying Good nurses get it and residents may not.
Focusing more intently means the surgeon may allow external distractions to continue but becomes more focused on his/her task at hand. Though they let conversations around them continue, they might drop out of those conversations themselves. If in a teaching setting, they might temporarily drop out of the teaching interaction.
Fine-tuning is the most subtle category and reflected minor transitions from the routine and might be considered a less intense manifestation of focusing more intently or removing distractions.
The term slowing down is really a misnomer since the surgeons hand movements and pace may not appreciably slow down. Rather it refers to the refocusing of attention that is taking place in the surgeons mind and transitioning from that more automatic mode to one where conscious effort is being focused an a task or situation at hand. This change is in response to some cues apparent to the surgeon that have alerted him/her of the need to change conscious effort. Those cues could be that a crucial stage of the procedure has been reached or that there is a peculiar situation encountered (eg. anomalous anatomy) or that a complication has occurred.
Interestingly, most of the surgeons in the study bristled at the premise they work on autopilot. Rather, surgeons felt that they always have a level of background situational monitoring but that, at certain times, they develop a heightened awareness of circumstances. However, they did recognize that sometimes a state of drifting might occur. It is during drifting that the background surveillance and situational monitoring may fail and these are times when they become prone to errors and adverse events.
The implications from a system perspective ought to be clear. It becomes critical that all the staff in the OR (or the cath lab or any variety of other sites doing procedures) need to recognize cues that the surgeon has switched to a more focused mode. In all likelihood they, too, need to refocus at such times. Its similar to what happens in an airplane cockpit. When the pilot (or sometimes the copilot) notes something unusual going on, he or she does a similar slowing down or refocusing and others in the flight crew should pick up on this.
The real lessons, therefore, logically are for team dynamics. This may be one factor that experienced teams that have long worked together do naturally. They may more readily recognize cues in the surgeons behavior that indicate the need to minimize distractions. The paper noted that sometimes the signs are very subtle and body language may say a lot more than verbal language. One surgeon noted he might start sweating a little bit or might not appear as happy.
So keeping well-functioning teams together makes a lot of sense. While a lot of organizations like to rotate their OR staff and anesthesiology staff so everyone gets to work with everyone else, perhaps the concept of long-term teams makes sense. Particularly in an academic/teaching situation the constant changing of personnel may be a challenge. The same authors also describe how surgeons handle the slowing down phenomenon in a teaching setting (Moulton 2010b), balancing direct (hands-on) control with overall control.
Can you teach people to look for cues that indicate slowing down has occurred? We dont know. However, we think that two team dynamics exercises might be of benefit. One is OR simulation. Most OR simulation programs have obvious disasters pop up and see how people respond. But maybe programming in some more subtle transitions might be useful. The second potentially useful exercise is videotaping OR procedures, then having all the staff view them and see if they can identify the subtle signs of transitions.
There remain many unanswered questions. The surgeons in this study were selected because of their good reputations. Do surgeons with lesser reputations respond in the same ways? Do the same dynamics hold during emergency operations and routine operations? Does fatigue (surgeon or staff) change the levels of background situational awareness or the transitions? Do diversity issues (both language and culture) interfere with recognizing the subtle cues during slowing down?
We dont know these answers. But this is a good paper to share with your surgical staff and your operating room teams. Well be it will generate lots of anecdotes about how the staff knows when individual surgeons reach a slowing down transition. But hopefully it will generate enough interest that they will begin to look for such transitions and take their own steps to minimize distractions and help the entire team focus during such periods.
Moulton C, Regehr G, Lingard L, Merritt C, MacRae H. Slowing Down to Stay Out of Trouble in the Operating Room: Remaining Attentive in Automaticity. Academic Medicine 2010; 85(10): 1571-1577
Moulton C, Regehr G, Lingard L, et al. Operating from the Other Side of the Table: Control Dynamics and the Surgeon Educator. J Am Coll Surg 2010; 210: 7986
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October 19, 2010
in the Elderly
This month weve seen a flurry of articles on optimizing medications in the elderly. Weve previously mentioned our experience with two programs dealing with review of medications in the elderly. One was Medicares Medication Therapy Management (MTM) program. The other was a home visit program through the Alzheimer Association. In both cases, patients medication lists were reviewed by a pharmacist or a nurse. When medications were identified that were either duplicative or possibly not necessary or possibly causing side effects, contact would be made with the patients physician. On the average, a couple medications would be dropped after every such review. Most frequently discontinued medications were those on Beers List of potentially inappropriate medications (see our January 15, 2008 Patient Safety Tip of the Week Managing Dangerous Medications in the Elderly and our Whats New in the Patient Safety World columns for June 2008 Potentially Inappropriate Medication Use in Elderly Hospitalized Patients and September 2010 Beers List and CPOE).
Now the results of an even more aggressive program addressing polypharmacy in the elderly was published in the Archives of Internal Medicine (Garfinkel 2010). Patients referred for comprehensive geriatric assessments had their medications assessed using the Good Palliative-Geriatric Practice (GP-GP) algorithm, which they had developed and piloted in a previous study of elderly disabled nursing home patients (Garfinkel 2007). The algorithm is very well thought out. Drugs are not discontinued or reduced in dosage in a random fashion but rather only after asking several relevant questions about evidence-based indications and dose levels in this age group, indication in the patients current functional or disability status, possible adverse symptoms or signs, etc.
There are a couple basic premises the authors have regarding medications in the elderly. One is that for many drugs we have a good evidence base for deciding when to start a drug but we have no evidence base for when to stop the drug (or when the benefits no longer outweigh the potential harms). Second, the evidence base for the favorable risk:benefit ratio usually comes from studies done on younger patients who often lack the multiple comorbidities seen in the elderly and who have considerably longer life expectancies. Patients in those clinical trials are also less likely to be on many other drugs that might influence either the efficacy or side effects of the study drugs.
They applied the GP-GP algorithm to 70 community-dwelling elderly patients and were able to discontinue drugs by an average of 4.4 drugs per patient overall. Only 2% of patients needed discontinued drugs restarted because of a recurrence of the original indication. Their overall successful discontinuation rate was 81%. No significant adverse events were felt to be attributable to the discontinuation and 88% of the patients reported a global improvement in health (with improvements in subjective clinical, functional, mood and cognitive spheres).
The list of drugs successfully discontinued was long and included not only psychoactive drugs like benzodiazepines and antidepressants and antipsychotic drugs, but also antihypertensives, diuretics, nitrates, statins, beta-blockers, H2 blockers and many others.
Though the sample size in this study was relatively small and the mean followup period was 19.2 months, it certainly demonstrates the feasibility of discontinuing a variety of drugs in the elderly and improving their overall health status. A larger, randomized controlled trial with longer followup might provide more definitive evidence that this approach is a successful one but the results of this study are certainly very encouraging. This will be particularly important since several of the drugs discontinued have been shown to be at least as effective (and in some cases more effective) at preventing the outcomes for the original indications.
The authors did not report cost data in this study but certainly one would expect cost savings for both the individual patients and for society as a whole. The earlier study, which had a control group for comparison, had identified a modest drug cost savings. However, the real question would be whether overall health care costs change with this approach. That is, one would like to see that discontinuation of drugs did not lead over the long run to more frequent hospitalizations, etc. Based on the improvement in global health reported, one might anticipate that discontinuation of drugs may actually lead to fewer hospitalizations over the long run and even bigger cost savings. And their earlier study (the one on the disabled elderly nursing population), though not randomized, did have a comparable control group and actually showed substantial reduction in both acute hospitalizations and mortality compared to that control group.
A key lesson here is that maybe our previous focus on Beers List drugs may have been too narrow and that in the elderly any attempt to reduce polypharmacy may lead to more desirable patient outcomes. As weve pointed out before, Beers List is a consensus-based list of drugs (with good evidence that the drugs could cause harm) rather than a true evidence-based list.
In the earlier paper, they suggested that at least for the elderly disabled hospitalized population, the well-known geriatric recommendation start low, go slow should be changed to stop most, reduce dose.
One other interesting point raised by the authors is that some of our pay-for-performance (P4P) programs may actually be leading to more aggressive prescribing of preventive medications in this patient population with the unanticipated consequence of worse health outcomes for the elderly.
Several other articles on medication use in the elderly were also published this month. Steinman and Hanlon (Steinman 2010) present a case of a clinically complex older patient and discuss multiple aspects of his medications. They provide a very thoughtful approach to how to assess which medications might be changed, reduced or discontinued, which medications might be underutilized, and how such changes might be accomplished. Part of this article includes a good discussion of the literature and evidence base for the sort of structured medication management approach (using clinical pharmacist, geriatrician, or the PCP). That evidence base, they conclude, is quite scant at this time.
A very thoughtful commentary by Jerry Avorn (Avorn 2010) discusses how healthcare policy changes might improve medication management in the elderly. He proposes reforms in medical school curricula in geriatrics and applied therapeutics, changes in reimbursement to recognize it takes longer to see an elderly patient with multiple comorbidities on multiple medications, better use of EMRs, and use of expanded Medicare databases to better determine risk:benefit ratios in patients who are historically underrepresented in clinical trials.
Finally, another article focusing on medication and falls (Boyle 2010) has an excellent review of the drugs associated with falls, particularly in the elderly. It concludes the evidence is strong for benzodiazepines, antidepressants, and antipsychotics increasing the risk of falls (and that there is no evidence that some of the newer agents in these categories are any safer with regard to falls). Antihypertensives, particularly diuretics, are associated with a modest increase in fall risk, as do NSAIDs (interestingly, narcotics do not appear to increase the fall risk). The article also describes many of the barriers (both physician and patient barriers) to withdrawal of medications that increase the risk of falls or to avoiding them in the first place.
So its been quite a month for good information about medication safety in the elderly!
Garfinkel D, Mangin D. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults. Addressing Polypharmacy
Arch Intern Med.2010;170(18):1648-1654
Garfinkel D, Zur-Gil S, Ben-Israel J. The War Against Polypharmacy: A New, Cost-Effective, Geriatric-Palliative Approach for Improving Drug Therapy in Disabled Elderly People. Isr Med Assoc J 2007: 9(6): 430-434
Steinman MA, Hanlon JT. Managing Medications in Clinically Complex Elders: "There's Got to Be a Happy Medium". JAMA. 2010;304(14):1592-1601
Avorn J. Medication Use in Older Patients: Better Policy Could Encourage Better Practice. JAMA. 2010;304(14):1606-1607.
Boyle N, Naganathan V, Cumming RG. Medication and Falls: Risk and Optimization. Clin Geriatr Med 2010; 26: 583-605
October 26, 2010
Many of the adverse events that occur in the operating room occur due to flawed processes. Many of those processes have counterparts outside the operating room where preventive measures have been instituted to successfully reduce the risk of the adverse events. Medication errors are one such area.
Most ORs today remain very different from the rest of the hospital in several key respects from a patient safety perspective. For example, most do not have electronic medical records and, even if they do, those EMRs may not be fully integrated with the EMR used by the rest of the hospital. Pharmacy IT systems are often not integrated with the OR. Bedside medication verification (barcoding) systems are not used in most ORs. ORs are particularly vulnerable to medication errors because the same person (i.e the anesthesiologist) is often responsible for ordering, dispensing and administering the medication. And the time pressures and emergency situations encountered in the OR further contribute to the occurrence of medication errors. Workarounds are also commonly used in the OR, often to save time and improve efficiency, but workarounds also introduce opportunities for error. One of the important patient safety tools used to prevent medication misadventures, particularly when dealing with high-risk medications, is the double-check process.
Our May 2008 Whats New in the Patient Safety World column UK NPSA Alert on Heparin Flushes cited a very good root cause analysis (Toft 2007) on several serious adverse events occurring in an anesthesia setting related to heparin misadministration. One of the many contributing factors uncovered in that RCA was the lack of double checks.
Weve often discussed the controversial aspects related to double checks (i.e. that the second checker is more prone to error and, in fact, both checkers may be more prone to error because they assume the other checker correctly verified all the information). Further, the phenomenon of involuntary automaticity (Toft 2005) may occur whereby repeated use of the checking process becomes so ritualistic that true cognitive double checks are not being done. And the process of double checking medications should be a selective and systematic procedure (Armitage 2007). However, studies have shown a roughly 30% reduction in drug errors with a double checking system.
So many have recommended that double checks be used to prevent medication errors in the OR and other situations using anesthesia. And a collaborative project in the UK has assessed the feasibility of confirming drugs administered during anesthesia. The study results were published in the British Journal of Anesthesia (Evley 2010). This study looked at two methods of confirming drugs during anesthesia: (1) a double-check system and (2) an electronic barcoding system. They concluded that, though both are feasible and likely to be effective in preventing medication errors, the double-check system has many obstacles that may make it impractical. On the other hand, the barcoding system was very practical and well-accepted into practice and provides a significant opportunity to reduce medication errors during anesthesia.
Details and additional materials from this study were released in an October 2010 data report from the UKs National Patient Safety Agency. The study was not designed to quantify the number of medication errors but rather to determine the feasibility of using either of the two methods in the anesthesia setting. Five sites used a double-check method and 2 sites a barcoding method. Focused interviews, independent observers, and reflective diaries were used to collect data on the feasibility of each method. The NPSA data report includes many examples of actual comments made by the participants and these are most revealing.
While the double-check system (that is, having a second person confirm the correct drug is being given) was felt by most to be a valid theoretical concept and did also raise awareness of the problem of medication errors, too many disadvantages were noted. Most notable among these was the fact that a second person had to be available. That second person was not always immediately available, especially during emergent situations when medication errors are especially likely to occur. Others perceived that the double-check also introduced delays into the progress of cases. As a result, workarounds popped up. For example, multiple medications might be confirmed at the same time, something we strongly frown upon in patient safety. Worse yet, there were times when the anesthetist or anesthesiologist would avoid giving a clinically indicated medication because the double check protocol would have been too intrusive. The comments in the report are worth reading. In many cases, they reflect culture of safety issues or simple resistance to change rather than being directly related to the double check process. In fact, it is telling that most of the participants felt that, though medication errors during anesthesia do occur, they are seldom serious and are usually dealt with satisfactorily.
Use of an electronic barcoding system, on the other hand, was much better accepted. It was an accurate way of confirming the medications and obviously did not require the presence of a second person. A few disadvantages were technical ones easily fixed (eg. moving the scanner closer to the site where the IV medications were administered). A big advantage was that this particular barcoding system was part of an electronic medical record that made recording of all anesthesia events much easier and made the anesthesia record readily available to others (such as the team in the post-anesthesia area that would soon be receiving the patient).
But there were downsides as well. There was a learning curve and minor glitches often had to be worked out after implementation. However, most significantly, workarounds allow one to bypass the patient safety aspect of the barcoding system in much the same way that they occur elsewhere (see our June 17, 2008 Patient Safety Tip of the Week Technology Workarounds Defeat Safety Intent). These included not scanning medications before administering them, scanning multiple medications prior to administration, etc. The most obvious downside is the capital investment required to get a barcoding system implemented and integrated with the hospitals pharmacy IT system and/or full EMR.
Though the study was not designed to demonstrate a reduction in actual medication errors in these settings (and realistically such a study is unlikely to get done soon due to the large number of patients and sites that would be needed), it does demonstrate that implementation of such systems is both feasible and practical.
Speaking of the OR, what about the ER! Almost all the comments we have made above apply equally to the emergency room. Many (well even say most) hospitals that have implemented bedside medication verification (BMV) barcoding systems and computerized physician order entry (CPOE) systems and electronic medical records (EMRs) on the inpatient side have not yet implemented these same patient safety features in either their ORs or ERs. Both sites deal not only with numerous medications but especially with high-risk medications. Should medication safety be less of an issue in those venues? Obviously not.
Toft B. Independent review of the circumstances surrounding four serious adverse incidents that occurred in the Oncology Day Beds Unity, Bristol Royal Hospital for Children on Wednesday, 3 January 2007. (UHBT Final Report Heparin). August 2007 www.ubht.nhs.uk/documents/oct_UBHT_final_report_heparin.doc
Armitage G. Double checking medicines: defence against error or contributory factor? Journal of Evaluation in Clinical Practice 2008; 14(4): 513519
Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Serv Manage Res 2005; 18: 211-216
Evley R, Russell, J, Mathew D, et al. Confirming the drugs administered during anaesthesia: a feasibility study in the pilot National Health Service sites, UK
Br. J. Anaesth. 2010; 105(3): 289-296
NPSA (UK). A collaborative project of the National Patient Safety Agency (NPSA), Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI). Feasibility of confirming drugs administered during anaesthesia
A qualitative study in pilot NHS sites, England and Wales. October 2010
November 2, 2010
Insulin: Truly a High-Risk Medication
As we were preparing this column on problems with insulin, we encountered a 2007 safety alert by ISMP on insulin-heparin mixups and thought to ourselves we havent seen much of this recently. Literally 2 hours after we said that, our literature-scanning software started popping up just-released news articles about a serious event in Canada in which four infants were inadvertently given insulin instead of heparin. The 2007 ISMP alert was issued after a neonate suffered severe hypoglycemia after insulin rather than heparin had been added to a bag of total parenteral nutrition (TPN). Ironically, the recent Canadian episode was an almost identical occurrence. Heparin was intended to be added to TPN but insulin (Humulin R) was added instead and the resultant mixture was administered intravenously to 4 neonates at the Canadian hospital. Staff noted the four infants worsening in similar ways and correctly diagnosed and managed the problem, though it is unknown whether any future neurological problems might result from the events.
Details of the root cause analysis (RCA) done at the Canadian hospital are not available though press reports indicate that similarity of the labeling on the two drugs likely played a role, as did insufficient space in the inpatient pharmacy. The hospital has apparently changed the labeling on insulin and heparin, added another safety check (?an independent double check), and is looking for additional pharmacy space.
Interestingly, ISMP Canada had also just released this August a bulletin on inadvertent administration of insulin to a nondiabetic patient, in whom a mixup of heparin and insulin was considered a possibility.
ISMPs 2007 alert highlighted multiple other instances of mixups between insulin and heparin. They noted that similar packaging, fact that both insulin come in 10 mL vials, fact that both are dispensed in units, and fact that vials of both are often kept near each other on countertops, in drug carts, and under pharmacy IV admixture hoods. They also noted that mental slips are involved in most instances. Perhaps contributing also is the fact that insulin infusions have been increasing in recent years.
ISMP made several recommendations to avoid such mixups during drug preparation:
However, probably the two most important issues are whether either heparin or insulin belong in the TPN solutions in the first place. The ISMP article discusses the pros and cons of using insulin separately or as part of TPN solutions. The issue of heparin (supposedly used to avoid IV catheter thrombosis) is also discussed in that ISMP alert. There is no evidence base to support the use of heparin for this purpose in peripheral IV lines. Though heparin flushes may improve umbilical catheter patency in neonates, there is no current good evidence to demonstrate its effectiveness and safety in peripherally placed central catheters in neonates. Weve previously discussed the issue of heparin flushes on multiple occasions.
The ISMP alert also had recommendations to help avoid heparin/insulin mixups at the point of administration:
Our original intent for todays column was to review multiple aspects of insulin use in the hospital setting. Insulin, of course, is one of the top 5 high-risk medications at virtually every hospital. It is of concern not only because of the frequency with which insulin is used but also the seriousness of the consequences of incorrect administration (or failure to administer).
Fortunately, in the past year there have been multiple great resources highlighting the pitfalls associated with insulin. There was an ISMP webinar on management of insulin, Pennsvylvania Patient Safety Authority Advisory on insulin errors (many of the lessons learned that appear in the ISMP webinar came from the Pennsylvania Patient Safety Reporting System so there is a lot of overlap in these two resources), and National Patient Safety Agency (UK) rapid response report on insulin issues. The NPSA site also has a good e-learning tool on safe use of insulin. And some older but equally important resources exist, including a monograph from ASHP (American Society of Health-System Pharmacists) and a good insulin audit tool from or the Victorian Medicines Advisory Committee (Australia).
The most egregious and potentially fatal errors with insulin have historically been related to use of the abbreviation U for units. The problem arises when the U looks like a zero so the patient inadvertently is given 10 times too high a dose. The same kind of problems can arise when the abbreviation IU for international units is used. The solution is to never allow use of either abbreviation. Its easy to put these abbreviations on your list of Do Not Use abbreviatons but in practice they still keep popping up. An area of particular vulnerability may be your IT systems. You need to purge these abbreviations from all your computer software. We have seen examples continue to pop up unexpectedly even years after we thought all such instances had been purged! They often show up in things like customized order sets or in materials coming from third party vendors. So you must have continuous surveillance for these occurrences. In addition, you need to make sure that your dictation systems automatically prevent use of these abbreviations. But even if you always use units rather than abbreviations, an order can still be misinterpreted depending on the presentation. If there is insufficient space between the number and units, particularly if the U in units is upper case, someone reading that order may still interpret the U as a zero. For example, NPH insulin 10Units might be interpreted as 100 units.
CPOE (computerized physician order entry) is the best way to reduce the risk of both handwriting errors and abbreviation errors. We also highly recommend using standardized order sets, whether paper or electronic, and glycemia management protocols whenever possible.
The large number and variety of insulin preparations is problematic. Add to that the look-alike/sound-alike (LASA) issue and it is no wonder that so many insulin errors occur. Think about all the insulin preparations that could easily be mixed up: Humulin, Humalog, Novolin, Novolog, Humulin 70/30, Humulin 50/50, Humulin R, Humulin N, Humulin L, Humulin U, Humalog Mix 75/25, Novolog 70/30, Novolog Mix 70/30, Novolin R, Novolin N, Novolin L. Use of tall-man lettering may help prevent some LASA mixups (eg. humuLIN, humaLOG, novoLIN, novoLOG, etc.)
One problem that may apply to a variety of insulin preparations occurs when the computer display screens, from which a provider is choosing an insulin dose and preparation, displays truncated information.
Many hospitals have attempted to limit the number of insulin preparations they keep in their formulary and some have sought to use multiple vendors to avoid confusion with look-alike vials. That, however, may be problematic because patients come into the hospital on certain preparations of insulin and expect to be continued on the same preparation while an inpatient. It can also become a nightmare for medication reconciliation when patients are discharged.
Another error being seen more frequently is related to the relatively new 500 unit insulin preparations. These preparations come in 500 unit per mL vials. The problem arises when healthcare workers use this dosage form with insulin syringes that a calibrated for 100 unit per mL insulin preparations (note there are currently no syringes calibrated for the higher concentrations). It is recommended that the 500 unit per mL preparations be stored completely separate from the other insulin preparations and only be used by specially designated healthcare workers who have received specific training in use of the higher concentration product. Certainly, they should never be stored as part of floor stock where they might be easily mixed up with the more common 100 unit per mL preparations. Better yet, dont stock this 500 unit per mL insulin at all! Unfortunately, the need for that higher concentration has been increasing in recent years as more obese patients with insulin resistance have been requiring much higher insulin doses. The higher concentrations may also be needed for patients having implanted insulin pumps. If you need to stock the higher concentration, make sure you have some mechanism (like a hard stop) to ensure that a pharmacist is involved in validating and preparing the dose and always have an independent double check before such preparations are administered.
Not only are incorrect doses of insulin a problem, but omitted or delayed doses are also a concern. Delayed doses become a concern especially when patients are transported to other areas of the hospital for testing, procedures, etc. Weve often seen patients spending several hours in the radiology suite, missing scheduled doses of insulin and becoming hyperglycemic or getting a full dose of insulin on return from radiology and then getting hypoglycemia. And in several of our columns on patient safety issues in the radiology suite we have mentioned that IV infusions sometimes get turned off during imaging procedures and these may not be restarted appropriately. If you use a structured tool for your inhospital transports, like Ticket to Ride (see our November 18, 2008 Patient Safety Tip of the Week Ticket to Ride: Checklist, Form, or Decision Scorecard?), be sure to include an item related to whether insulin should be given or held while the patient is off the floor.
Another problem in insulin omission we have encountered relates to the timing of admission orders. Some pharmacy computer systems are programmed to dispense the every morning doses of drugs at 8AM the next morning. We have seen examples where a diabetic patient has admission orders written in the emergency room at 7:30AM but does not have those orders transcribed and entered into the computer system until 8:30 AM. In such cases, there is a risk that a patient could go 24 hours without an insulin dose (and without his or her other daily medications). Handoffs in such situations are critical in ensuring that patients get their intended doses of medications on the correct day.
One error we have encountered on numerous occasions is failure to inquire during medication reconciliation about the time the last dose was taken. We have seen this lead to failure to give any insulin on the day of admission or to delays in insulin administration when patients undergo long delays between presentation to the emergency room and ultimate admission to the hospital. On the other hand, it can also lead to inadvertent administration of two doses in one day (i.e. the patient took a dose at home and gets a repeat dose in the hospital). Your medication reconciliation forms, whether paper or electronic, need a column for time last dose taken. While that may be of little consequence for many drugs, it is clearly very consequential for high-risk drugs like insulin.
An excellent patient safety intervention for high-risk drugs is setting dose range limits on your CPOE or pharmacy IT systems. This is very valuable in preventing, for example, overdoses of chemotherapy agents. For insulin, it is much more difficult than it sounds. That is because the dosages of insulin used are so variable across patients. But it is worth looking at your data and saying weve seldom used a dose of insulin exceeding x units and then adding an alert that helps physicians, pharmacists or nurses question orders for large doses of insulin.
A discussion about sliding scale insulin therapy is beyond the scope of todays column. However, suffice it to say that such practice has become frowned upon (though every hospital weve ever visited has examples where someone is still using it!). The PPSA Advisory on insulin errors has a good discussion on this issue and provides numerous examples of problems arising from sliding scale or insulin coverage orders. When insulin is being given based on the results of bedside glucose testing (glucometers), there have been multiple instances where nursing notes scribbled on a pad for multiple patients have led to patient weights or even room numbers being mistaken for glucose levels!
The syringes used to administer insulin have been a source for errors in insulin management. Insulin is supposed to be prepared and administered in special syringes calibrated in units. These are usually one mL syringes standardized for 100 units per mL insulin preparations. A serious problem arises when someone tries to administer insulin from regular intravenous syringes. In the latter the calibrated markings indicate volume, not units. So a provider erroneously using such a syringe might fill it to 4 mL, thinking this means 4 units, and actually be administering 400 units of insulin!
Use of insulin pens has increased substantially in recent years, with many advantages. However, one must be very careful that insulin pens are never used on more than one patient since there have been numerous examples of cross contamination with blood-borne diseases from insulin pens (FDA 2009).
Another practice being used more and more is the insulin drip. A good recent article (Maguire 2010) discusses how in many hospitals insulin drips are not just being used in ICU settings but are also being managed on regular floors. Note, however, that the PPSA Advisory on insulin errors noted several cases where IV bags containing insulin were mistakenly hung instead of other IV medications.
A real problem nowdays is related to the use of hospitalists. While we are huge advocates of hospitalist programs, we are seeing problems arising when patients are co-managed by more than one physician. In particular, we often see patients on surgical services having their diabetes managed by hospitalists (or other consultants). In such cases it needs to be made very clear to nursing staff who will be responsible for the insulin and diabetes management orders.
Independent double checks are often recommended when we are dealing with administration of high-risk medications. Even though we have emphasized that double checks are a relatively weak intervention (we know from all industries that the error rate when a supervisor checks someone elses work may be 10% or higher), the literature supports a medication error reduction of about 30% when using a double check system (see our July 15, 2008 Patient Safety Tip of the Week Heparin Flushes.....Again!). Also, for any high-risk medications you need to do truly independent double checks (see our March 30, 2010 Patient Safety Tip of the Week Publicly Released RCAs: Everyone Learns from Them for a description of independent double checks). Another nice article on independent double checks in preventing medication errors (ISMP Canada 2005) describes the independent double check process and calculates that independent double checks would reduce the error rate of a process having an error rate of 5% all the way down to 1 in 400.
One last problem in managing patients on insulin deals with those patients having insulin pumps. Both external and implantable insulin pumps may present risks during MRI procedures (Shellock 2010). The pump motors may be damaged by exposure to the high electromagnetic fields generated during MRI. So in many cases the pump (and in some cases the transmitters or sensors) may have to be removed prior to entering the MRI environment. The Shellock article provides details for each pump by manufacturer for what to do prior to MRI and also what to do if a patient with an insulin pump is inadvertently exposed to MRI.
So what should your organization be doing to reduce errors related to use of insulin? We have several recommendations:
We have developed over the years a healthy respect for the complexities associated with use of insulin and its potential dangers. Insulin is truly a high risk medication and deserves a unique position in your patient safety activities.
ISMP (Institute for Safe Medication Practices). Action needed to prevent dangerous heparin-insulin confusion. ISMP Medication Safety Alert Acute Care Edition 2007; May 3, 2007
Region's handling of error angers moms. Babies given insulin instead of blood thinner
By Lana Haight, The StarPhoenix October 23, 2010
Premature babies mistakenly given insulin in their IVs.
By Hannah Scissons, The StarPhoenix October 21, 2010
Changes made after 4 babies given wrong drug
The Canadian Press
21 October 2010
Baby dies 2 weeks after given wrong drug
The Canadian Press
22 October 2010
ISMP Canada. Inadvertent Administration of Insulin to a Nondiabetic Patient. ISMP Canada Safety Bulletin 2010; 10(6): 1-3 August 31, 2010
ISMP Teleconference October 15, 2009. High Alert Medications Series Part IV. Preventing Errors from Insulin: A Multidisciplinary Approach
(you can purchase the CD at this website)
Pennsylvnia Patient Safety Authority. Pennsylvania Patient Safety Advisory. Medication Errors with the Dosing of Insulin: Problems across the Continuum .Pa Patient Saf Advis 2010 Mar;7(1):9-17
NPSA (UK). Rapid Response Report. Safer administration of insulin. June 2010
the report: Safe administration of insulin.
e-learning module on safe use of insulin
American Society of Health-System Pharmacists; Hospital and Health-System Association of Pennsylvania. Professional practice recommendations for safe use of insulin in hospitals. Rockville (MD): American Society of Health-System Pharmacists
Victorian Medicines Advisory Committee. Subcutaneous insulin audit tool. Melbourne (Australia): State Government of Victoria Department of Health
FDA. Information for Healthcare Professionals: Risk of Transmission of Blood-borne Pathogens from Shared Use of Insulin Pens. FDA Alert March 19, 2009
ISMP Canada. Lowering the Risk of Medication Errors: Independent Double Checks. ISMP Canada Safety Bulletin. January 2005
Shellock FG. MRI safety: Patients with insulin pumps require special cautions. DiagnosticImaging.com October 5, 2010
Maguire P. IV insulin on the floor: not so scary after all. How a protocol first championed by hospitalists has been embraced by nurses. Todays Hospitalist 2010 (October 2010)
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
Weve often been asked what we think about 12-hour shifts for healthcare workers from a patient safety perspective. In light of significant workforce shortages of not only nurses but also pharmacists and technologists and also economic challenges to hospitals, we are seeing the 12-hour shift implemented more and more frequently. So weve been searching for objective evidence of the impact of such schedules on patient safety. Youll have no problem finding papers about the impact of 12-hour shifts on a variety of parameters. In fact, whether you are for or against such shifts youll have no problem finding a paper to support your position! But much of the literature is based upon anecdotal evidence (though dont forget anecdotes and stories are often our most powerful patient safety tools!) or studies lacking valid scientific design.
The 2004 Institute of Medicine Report Keeping Patients Safe: Transforming the Work Environment of Nurses, recommended that policies be adopted to prevent nurses in direct patient care from working more than 12 hours in a 24-hour period and 60 hours in a 7-day week. But unlike the situation where we have put official restrictions on the hours that medical residents can work, no such limits have been formalized for nurses to date.
Much of the work on 12-hour vs. 8-hour shifts comes from industries other than healthcare. For an excellent summary of the advantages and disadvantages of 12-hour shifts in any 24/7 industry, see the white paper by Moore-Ede et al of Circadian Technologies, Inc. (Moore-Ede 2007). And, though somewhat old already, a review by Smith et al. (Smith 1998) summarizes the impact of 12-hour shifts on multiple different parameters. Advantages in many industries include increased productivity, fewer errors, fewer handoffs, increased continuity, reduced absenteeism, reduced turnover and better morale. For workers, more days off and longer breaks away from work, allowing for improved family and social life are major factors that have led many workers to like 12-hour shifts. A study done in New York City hospitals (Stone 2006) showed that nurses working 12-hour shifts were more satisfied with their jobs, had less emotional exhaustion, and less absenteeism than nurses working 8-hour shifts, all without impacting patient outcomes. One key element to worker satisfaction with 12-hour shifts seems to be how the change was developed and implemented. Where workers had a voice in developing the system, rather than having it imposed on them, satisfaction levels are much higher.
The real problem in assessing the impact of shift duration on patient safety is the same one we have in most areas of patient safety: lack of reliable, easy to collect outcome measures. Its not like we can look at the number of defective widgets per hour and correlate that with shift duration.
Perhaps the most quoted study linking medical errors to shift duration is that by Rogers et al. (Rogers 2004). In that study nurses were randomly chosen and asked to participate in a study in which they kept log books for two 2-week periods. About 40% of those chosen responded and these were representative of the nursing population as a whole in terms of demographics and other factors. The log books contained up to 40 questions per day on days worked and 17 per day on days off. Nurses recorded not only data about hours worked, shift duration, overtime, etc. but also included self-reported errors and near errors. The study clearly showed increasing error rates with increasing duration of shifts. The odds ratio for making an error was 3.29 for nurses working more than 12.5 consecutive hours and the odds ratio was 2.06 for nurses working any time longer than their scheduled shift. Of the errors reported, 58% involved medication administration, 18% procedural errors, 12% charting errors, and 7% transcription errors.
The same group later demonstrated similar findings in a randomly selected sample of critical care nurses (Scott 2006). That study also found a correlation between shift duration and nurses difficulty staying awake, though they were not able to demonstrate an association between that and the increased risk of errors.
In both those studies, the other striking (but no surprise to us) finding was that nurses almost never go home at the end of a scheduled shift. In fact, in the second study only 1 out of 502 respondents reported leaving on time at the end of a shift. Nurses worked on average 55 minutes longer per shift and two-thirds of the nurses worked overtime 10 or more times during the 4-week study periods.
So what, if anything, is wrong with these studies and why arent we restricting duration of nursing shifts? The study used self-reported errors and near errors as outcome measures. We dont have a problem with that. We know that incident reporting systems and even medication error reporting systems significantly underreport errors and that anonymous reporting systems do a much better job of capturing errors and events. The biggest concern is that there are multiple confounding variables that may have had an impact on the results of these studies.
First, and formost, is that the studies did not include strict 12-hour shifts (though as the studies pointed out, there may be no such practical entity as a strict 12-hour shift). Obviously the amount of overtime worked by the nurses likely had a big impact. We also are not told about 2 very important factors that may have played a role: (1) handoffs and (2) effect of consecutive days worked.
One of the potential beneficial aspects of 12-hour shifts is the reduction in handoffs. In fact, in most industries that reduction in handoffs is touted as the most important benefit of 12-hour shift. Instead of the three handoffs seen with 8-hour shifts, you only have two handoffs with 12-hour shifts. And, just as importantly, you are typically handing off to the same individuals that your received a handoff from at the start of your shift (adding an element of I want my handoff to be as good as the one I expect to get). Weve talked about the problems that arise as the result of fumbled handoffs in numerous columns (see our April 2010 Patient Safety Tip of the Week Update on Handoffs, which has links to all the other handoff columns).
The second is a very interesting phenomenon seen when one looks at error rates by day of the week. It turns out that in a typical 5-day work week you make more errors toward the end of the week. Well call this the consecutive day phenomenon. A study on shift workers in fields other than healthcare (Folkard 2003) showed that the risk of incidents increased each consecutive day worked . For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%). That same study demonstrated that risks are not uniform throughout the day but are greater at certain times, especially at night, and even vary based upon temporal relationship to breaks. Those authors stress that all these factors (number of successive night shifts, length of night shifts, and provision of breaks) must all be considered in combination. They note it is conceivable that a 12-hour night shift with frequent rest breaks might well prove safer than an 8-hour shift with only one mid-shift break.
In an excellent 3-part series this year Is It Time to Pull the Plug on 12-Hour Shifts? by Geiger-Brown and colleagues, Part 1 describes the negative aspects of 12-hour shifts on multiple different parameters. These include not only potential patient outcomes, but also needlestick injuries, musculoskeletal and other work-related injuries, and increased rates of motor vehicle collisions or near-misses while driving home from extended shifts. They also discuss potential health consequences of long-term sleep deprivation. Part 2 describes the barriers to reverting to shorter shifts, not the least of which is that nurses often like the 12-hour shifts for a variety of reasons. And Part 3 is an excellent set of recommendations for organizations to take to mitigate the potentially negative effects of 12-hour shifts if you have to live with them. Key amongst those recommendations is limiting the shift (i.e. no overtime and avoiding things like meetings at the end of shifts) and respecting days off (not calling nurses in to work on their scheduled days off). They also recommend use of scheduling software that takes into account health conditions and other factors that may overtax nurses working long shifts. Improvements in physical layouts and the environment can also remove some of the stressors that contribute to fatigue. They also have some great suggestions for protecting nurses working the night shifts (use of buddy systems, planned power naps, avoiding certain types of tasks during the bodys circadian nadir around 2-4 AM, and encouraging nurses to speak up when they are tired). Very important are some other suggestions relating to health of the nurses, such as having food sources other than vending machines, and having caffeinated beverages available up to (but not beyond) 11 PM. They even have recommendations about appropriate use of sunglasses on leaving the hospital in the morning.
Communication when working in a 12-hour shift environment may also be challenging. As above, you need to make sure you do not schedule meetings or training sessions at either end of the 12-hour shift so you have to make other accommodations for those. Many have suggested that other means of communication (written, email, web-based, etc.) may need to be implemented when 12-hour shifts become the norm. Also, when nurses are away for longer periods of time (one of the advantages of 12-hour shifts that many nurses like) there may be a need for reorienting when the nurse returns.
One observation noted in multiple studies is that though fatigue and slowed cognitive processes were documented with various tools, nurses (or residents or other healthcare workers) were often able to rise to the occasion when faced with serious medical problems. It seems that errors tend to be more problematic with more mundane, repetitive sorts of tasks. The paradox between fatigue and slowed cognitive function vs. productivity has also been seen for medical residents. Whereas Dula et al (Dula 2001) had demonstrated that residents cognitive ability declines over the course of consecutive overnight shifts, another study (Jeanmonod 2009) demonstrated that for ER residents productivity (defined as number of patients seen per hour) actually went up on consecutive days through at least 5 days.
Multiple studies have also demonstrated that people (in any industry, not just healthcare) tend to underestimate their levels of fatigue and impairment compared to their performance on formal testing. Some day we will have the equivalent of the brief sobriety test that can rapidly identify healthcare workers who are impaired by fatigue.
There obviously are very many unanswered questions regarding 12-hour shifts for nurses or other healthcare professionals. A lot has changed since some of the field studies on impact of these shifts was first done. Undoubtedly, our high tech tools (bedside medication verification by barcoding, CPOE, etc.) have changed the environment but we dont know whether that mitigates or exacerbates the problems associated with 12-hour shifts. Were only likely to solve this with a well-designed study with hard outcome parameters done in a setting where a legitimate control group can be used (for example, implementing 12-hour shifts on one or several med/surg floors where the other comparable floors maintain their current 8-hour shifts). Even then, a way to account for all the potentially confounding factors noted above must be found.
Our best advice for the present is to be wary of potential patient safety issues if you are using 12-hour nursing shifts and implement the recommendations in the Geiger-Brown articles.
IOM (Institute of Medicine). Page A (ed). Keeping Patients Safe: Transforming the Work Environment of Nurses.Washington: National Academies Press, 2004
Moore-Ede M, Davis W, Sirois W. Advantages and Disadvantages of Twelve-Hour Shifts: A Balanced Perspective (white paper). CIRCADIAN 2007.
Smith L, Folkard S, Tucker P, Macdonald I. Work shift duration: a review comparing eight and 12 hour shift systems. Occup Environ Med 1998; 55: 217-229
Stone PW. Du Y. Cowell R. Amsterdam N. Helfrich TA. Linn RW. Gladstein A. Walsh M. Mojica LA. Comparison of Nurse, System and Quality Patient Care Outcomes in 8-Hour and 12-Hour Shifts. Medical Care 2006; 44(12): 1099-106, 2006 Dec
Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The Working Hours Of Hospital Staff Nurses And Patient Safety. Both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours at a stretch.
Health Affairs 2004; 23(4): 202-212 July/August 2004;
Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of Critical Care Nurses Work Hours on Vigilance and Patients Safety. Am J Crit Care 2006 15(1): 30-37
Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101
Geiger-Brown J, Trinkoff AM. Is It Time to Pull the Plug on 12-Hour Shifts? Part 1. The Evidence. Journal of Nursing Administration 2010; 40(3): 100-2, 2010 Mar
Lothschuetz Montgomery K. Geiger-Brown J. Is It Time to Pull the Plug on 12-Hour Shifts? Part 2. Barriers to change and executive leadership strategies.
Journal of Nursing Administration. 40(4):147-9, 2010 Apr.
Geiger-Brown J. Trinkoff AM. Is It Time to Pull the Plug on 12-Hour Shifts? Part 3. harm reduction strategies if keeping 12-Hour Shifts. Journal of Nursing Administration 2010; 40(9): 357-9, 2010 Sep
Dula DJ, Dula NL, Hamrick C, Wood GC. The effect of working serial night shifts on the cognitive functioning of emergency physicians. Ann Emerg Med 2001; 38(2): 152-155
Jeanmonod R, Damewood S, Brook C. Resident Productivity: trends over consecutive shifts. Int J Emerg Med 2009; 2: 107-110
November 16, 2010
Lost Lab Specimens
In our September 16, 2007 Patient Safety Tip of the Week Errors in the Laboratory we discussed the tragic issue of pathology specimens being mixed up. In such cases a patient may undergo an unnecessary surgical procedure for an erroneously diagnosed cancer, and the other patient may have a delayed diagnosis of his cancer.
Another potentially tragic error is loss of surgical specimens. How would you feel if you underwent an invasive procedure with biopsy and your specimen got lost? At best, you could undergo another biopsy, though youd have to endure the risks and inconveniences of that second procedure. At worst, there would be no place to look for more tissue (eg. after removal of a skin lesion suspected of being a malignant melanoma) and your anxiety levels would soar over the uncertainty.
There arent any great statistics on how often surgical specimens are lost. One study (Makary 2007) looking at surgery in an outpatient clinic or a hospital operating room found 4.3 surgical specimen identification errors in every 1000 cases (and about 60% of those errors were in biopsies)but did not note cases of lost specimens. The Pennsylvania Patient Safety Authority did a Patient Safety Advisory Lost Surgical Specimens, Lost Opportunities in 2005. They had received at least 30 reports of lost surgical specimens through their patient safety reporting system but did not provide any denominator data so the actual rates of lost specimens is unknown. Fortunately, these are probably rare events. However, they can be devastating to patients and staff when they occur.
After a near-miss where surgical biopsy specimens were temporarily misplaced (but fortunately found in a few days), we helped in a root cause analysis (RCA) to get a better understanding of the vulnerabilities. Technically, it was really a FMEA (Failure Mode and Effects Analysis) since we went well beyond the RCA and looked at the entire pathway that a specimen would follow from the OR (or office) through final reporting of pathology.
We began by flowcharting the entire process. After you do your initial pass at flowcharting, you need to go back and ask questions like How is that handled after hours (at night or on weekends)?.
Key to doing a good RCA or FMEA is involving the key players who are closest to the process. They are the ones most likely to tell you where the problematic points are (and tell you the solutions!). You also need to visually observe the entire process as it plays out in real time. You will be surprised at how often you see things that others have come to accept as normal. And youll see the various workarounds that have crept into the process.
Many who have done similar RCAs or FMEAs have chosen the start of the process to be when the specimen is taken from the patient in the OR. However, it really should begin well before that. When a case is booked onto the OR schedule one of the questions that should be asked is Do you anticipate there will likely be surgical specimens to be sent to the lab?. Then, during the pre-op huddle or pre-op briefing that question should be asked again.
The OR surgery/procedure documentation sheet should contain a section detailing what specimens were obtained and sent to the laboratory. In fact, we recommend you also have a check box for when no specimen is sent and have the surgeon sign or initial that box when no specimens are sent.
Using forms or checklists may help remind people what to do with the specimen. If you use the World Health Organizations Surgical Safety Checklist the Sign Out phase is completed before the patient leaves the operating room. The Checklist coordinator verbally confirms the name of the procedure, the instrument and sponge counts, correct labeling of any specimens, any equipment problems, and key concerns for postoperative care and recovery.
Labeling specimens should take place immediately when the specimen is removed in the OR. Specimens are usually given to a nurse in the OR, who then puts the specimens in a container with the patients identification (at least 2 methods of patient identification), date/time taken, surgeons name, and description of the tissue (what it is and where it was taken from) and a requisition slip with similar information. The containers with the specimens are then generally placed in a receptacle in the pick-up area of the OR nurses station and entered into a log book. Specimens are in formalin in the small containers but larger specimens need to go in larger containers. Formerly, nurses in the OR would add formalin to the larger containers but that practice had been stopped for safety reasons (so formalin is added to the larger specimens in the lab itself). The specimens are then taken by someone (in this case, that someone could be a nurse, a courier, or anybody who happened to be going to the lab). That person would sign the log book in the OR and take the specimens to the lab. At the lab they would sign a log book, as would the person receiving the specimens in the lab. After logged in at the lab the specimens are taken by the technician to the grossing section and the technician prepares cassettes to be matched to each specimen. The pathologist then does a gross examination (dictating his/her report) and places specimen parts into the labeled cassettes. From there the specimens are put into the processing machine overnight. A technician maintains the lab log and indicates on there how many cassettes the pathologist listed in his dictated report. However, sometimes the technician does not hear the dictation until the following morning. In the morning the technician removes the cassettes from the processing machine and takes them to the embedding machine (paraffin bath). From there they go to a microtome where slides are prepared and labeled. They then go to a warming oven to dry, then are cooled off, and stained. Once stained and dried the slides are placed in a slide holder and placed, along with the corresponding gross descriptions, on the pathologists desk. The pathologist adds the microscopic examination to his report and the slides are put in a filing cabinet for storage. This is the process that takes place at most labs.
Several similar RCAs or FMEAs using this type of flowcharting appear in the literature (Slavin 2001, Messinger 2010). One good article on issues related to lost specimens (OR Manager 2007) provides some examples that occurred at hospitals. It provides details about policy and procedure changes that were implemented after a lost specimen, including a copy of the specimen handling policy adopted at that hospital (Swedish Medical Center 2007).
Chain of custody is a term usually associated with precise tracking of forensic specimens or evidence in legal cases. Most labs at times do have to adhere to strict chain of custody procedures when they do handle items involved in litigation. Yet shouldnt every specimen be handled with the same level of scrutiny and security? I would certainly hope any specimen of mine were handled that way! Chain of custody is nicely described in the PPSA Patient Safety Advisory Lost Surgical Specimens, Lost Opportunities and the OR Manager article. It usually involves logs containing the names/departments releasing the specimen, names/departments accepting the specimen, dates and times of such transfers, patient identification, specimen number, specimen description, and others.
Lacking are good studies demonstrating the impact of new technologies (barcoding, RFIDs, etc.) on tracking lab specimens. We dont doubt that these will play a primary role in specimen tracking very soon. After all, if Fedex and UPS can tell you where your package is at any moment in time, why cant a hospital do the same? Two articles (Malone 2010, Soom 2010) in the July 2010 issue of Clinical Laboratory News discuss those new technologies and their role in tracking specimens.
One very simple intervention that should be done at all handoffs is a specimen count. If you knew you had 14 specimens or cassettes at Step B and you now have only 13 at Step D, you have at least isolated the locations where the specimen was most likely lost or misplaced. Its just like doing a sponge count when your are doing surgery. (Speaking of spongesone cause of lost specimens is when tiny tissue specimens get attached to small sponges that may be put in specimen containers).
During the discussion with key stakeholders, anecdotal items tend to come out. Apparently sometimes the receiving person in the lab after hours did not always put the larger specimens in formalin. Pathologists often grumble that the surgeons dont provide enough detail about the specimens.
What happens after hours probably differs from facility to facility. In our RCA the OR nurse would deliver the specimen to the lab and turn it over to whoever was working in the lab that night (that might be someone other than the normal tissue lab technician). One must be certain that the person receiving specimens after hours is as fully trained in proper handling and processing of those specimens as your day staff are.
Specimens coming from outside the hospital via courier (eg. from offices) can be especially problematic. You may have little control over the labeling and handling that occur in those offices. And there are lots of anecodotes of such specimens never reaching the lab. It may make sense to have some communication from the offices to the lab ahead of time, notifying them that a specimen or specimens are on their way to the lab. In any event, the logbook and chain of custody procedures should take place every time a handoff takes place (eg. office-to-courier, courier-to-lab, etc.) and specimen counts should match.
One other caveat that comes from the literature on mislabeling of specimens: if you can avoid it, dont batch! Deal with specimens one at a time. Any time you are dealing with labeling multiple specimens at the same time you run the risk of transposing labels.
Ownership becomes a key element. In the Slavin article, the pathology department decided that it would take ownership of the transport process from the OR to the lab. That effectively reduced the number of handoffs. Handoffs are always opportunities for errors to occur so anything that reduces the number of handoffs generally improves safety. In our own RCA/FMEA the OR staff decided to take ownership for the process when done after hours (taking the specimen to the lab, entering it into the log there, and putting it in formalin). This step basically says we will not assume that someone else will do it. Another example was our lab staff deciding to take over removal of the waste receptacles (rather than housekeeping) so they would have control in the event of a missing specimen.
Having a checklist where to look for lost specimens may also help. This should include places where previously misplaced specimens were ultimately found and should point staff to review the chain of custody logs to identify where the specimen was last recorded.
Having outsiders (i.e. people who do not ordinarily work in the pathology lab) observe the process also provides an opportunity to observe the work environment. That is where the little things, that escape the attention of the lab personnel, may be identified. For example, you might notice that the trash receptacles sit in locations where it might be possible to accidentally knock a specimen or cassette into them (dont be afraid to ask them Have you ever knocked a cassette into that trash can?). Or you might notice that all the specimen containers and their matching cassettes are lined up like dominoes and vulnerable to being knocked over by an errant elbow!
Review of the work environment should include attention not only items like lighting and clutter but also workload issues. Mistakes tend to occur most often under stressful conditions, such as time pressures or deadlines, understaffing, fatigue, conflicting goals and incentives, etc.
Any time we implement a quality improvement project we need some metrics to track and demonstrate that our changes induced positive outcomes. The ultimate outcome goal is obviously to avoid any lost specimens at all. Given the rarity of lost specimens, monthly tracking of lost specimens is likely to produce lots of useless graphs. Hence, some organizations looked for proxies or surrogate measurements that could be used to demonstrate improvement. One (Messinger 2010) chose to monitor misplaced specimens (where specimens were temporarily lost but eventually found) and was able to use control charts to monitor processes. Another (Slavin 2001) used timeliness of specimen processing as a proxy for potential lost specimens. They felt that since overall processing time is a function of how long a specimen sits in one or more areas, this would be a good surrogate for potential lost specimens. They incorporated that measure into control charts and were able to demonstrate that their QI project was producing desirable results.
Education, training and competency assessment are, of course, essential to quality in any laboratory setting. But dont forget you also need to make sure everyone who might be in that laboratory, including your housekeeping staff, understand security of specimens.
Prompt communication upon identifying a lost specimen is critical. That communication starts the search for the missing specimen. Such cannot be delayed. For instance, if the specimen is in a trash can it may be gone and irretrievable by morning. Similarly, if your specimen count on arrival at the lab does not match what was in the logbook at the OR end, an immediate call to the OR is needed to avoid having a specimen discarded along with the other surgical paraphernalia.
Obviously, this is a great topic for your organization to consider for a FMEA (Failure Mode and Effects Analysis). Flowcharting the entire process from pre-procedure through the entire pathology process will help you identify not only potentials for losing specimens but also those potentials for mislabeling specimens and mixing them up.
Update on specimen mixups: Since our September 16, 2007 Patient Safety Tip of the Week Errors in the Laboratory where we discussed pathology specimens being mixed up, we have come across some other good articles on mislabeling and mixups of surgical specimens (Layfield 2010, Lippi 2009 , Nakhleh 2003, Valenstein 2004, Astion 2006).
Makary MA, Epstein J, Pronovost PJ et al. Surgical specimen identification errors: A new measure of quality in surgical care. Surgery 2007; 141(4): 450-455
Pennsylvania Patient Safety Authority. Lost Surgical Specimens, Lost Opportunities.
PA PSRS Patient Saf Advis 2005 Sep; 2(3):1-5
WHO Surgical Safety Checklist
Slavin L. Best MA. Aron DC. Gone but not forgotten: the search for the lost surgical specimens: application of quality improvement techniques in reducing medical error.
Quality Management in Health Care 2001. 10(1): 45-53
Messinger B, Ahlin P. Patient Safety Focus: Lost Versus Misplaced Samples. Improving Lab Quality with Pull Measures. Clinical Laboratory News 2010; 36(1): January 2010
OR Manager. Taking steps to protect patients from specimen-handling errors. OR Manager 2008; 24(12): 1, 7-8
Swedish Medical Center. Specimens: Labeling and Handling (Clinical Procedure). August 2007. Downloaded from OR Manager Toolbox.on ormanager.com website.
Malone B. Radio Frequency Identification of Specimens. Can it Solve Labs Preanalytical Predicament? Clinical Laboratory News 2010; 36(7): July 2010
Soom S, Strathmann F. Patient Safety Focus: How Labs Can Protect Against Specimen Loss. Clinical Laboratory News 2010; 36(7): July 2010
Layfield LJ. Anderson GM. Specimen labeling errors in surgical pathology: an 18-month experience. American Journal of Clinical Pathology. 134(3):466-70, 2010 Sep.
Layfield LJ. Anderson GM. Specimen labeling errors in surgical pathology: an 18-month experience. American Journal of Clinical Pathology. 134(3):466-70, 2010 Sep.
Lippi G, Blanckaert N, Bonini P, et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. (Review). Clinical Chemistry & Laboratory Medicine 2009; 47(2): 143-153, February 2009.
Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clinics in Laboratory Medicine 2007; 24(4): 979-996
Astion M. AHRQ WebM&M. Right Patient, Wrong Sample. December 2006
Nakhleh RE. Lost, Mislabeled, and Unsuitable Surgical Pathology Specimens. Pathology Case Reviews 2003; 8(3): 98-102
Print Lost Lab Specimens
November 23, 2010
Focus on Cumulative
Earlier this year we chronicled several recent revelations about excessive patient exposure to radiation through various medical interventions (see our February 2, 2010 Patient Safety Tip of the Week The Hazards of Radiation and March 2010 Whats New in the Patient Safety World column More on Radiation Safety). In those we discussed not only the risk of radiation exposure from single studies but also the cumulative radiation exposure risk and the fact that currently no one is tracking that for our patients not we as physicians, not health systems, and not the patients themselves.
While much of the previous discussion centered around imaging studies like CT scanning, a new paper (Einstein 2010) focused on another at-risk population: those receiving imaging studies for cardiovascular disorders. They looked at over 1000 consecutive patients who presented to Columbia University Medical Center for myocardial perfusion imaging and measured or estimated the total dose of ionizing radiation those patients received prior to and in the subsequent 2+ years. These nuclear isotope imaging studies are among those tests with the highest radiation burdens and are often followed by other studies with more radiation (eg. prolonged fluoroscopic exposure during cardiac catheterization, etc.). Moreover, many of these patients end up getting one or more followup perfusion imaging studies (20% had at least 3 such studies and 5% had 5 or more). They found that almost 40% of the patients had a cumulative radiation exposure higher than that seen in the large study of Japanese atomic bomb survivors. So clearly the radiation exposure here is of the magnitude known to be potentially carcinogenic (though keep in mind that many of these patients are older and have medical conditions that will shorten their lifespan so they may not live long enough to get cancer).
The authors point out that these were tests for which the patients had appropriate medical indications. However, they point out the need to consider the big picture when planning for evaluation and management of such patients. Specifically, both past and potential future radiation exposure need to be considered when deciding on ordering tests on these patients. There are alternative methods of testing in the chest pain patient that do not utilize ionizing radiation (eg. stress echocardiography, stress MRI, conventional treadmill exercise stress tests, etc.). Also, even more of a problem is layering of tests. For example, a chest pain patient may get a nuclear myocardial perfusion study, then a cardiac CT angiogram or PET scan, then a cardiac catheterization). In some cases, particularly in the highest risk patients, it makes more sense to go first with the most definitive test because it may result in the least cumulative radiation exposure (and may actually also be the least costly approach). National and specialty society guidelines need to do a better job of considering cumulative radiation dose when recommending algorithms for workup of various medical conditions.
Of even more concern is the cumulative radiation dose given to younger patients, particularly pediatric age group patients. The potential for cancer development as a result of radiation exposure is much greater over their longer lifetimes. Yet children presenting to emergency rooms or urgent care centers with abdominal pain frequently get CT scans to rule out appendicitis, when ultrasound examination (which does not use ionizing radiation) could suffice in many cases. Similarly CT scans of the head or X-rays of the ankle and knee are often done in the pediatric ER population that could be avoided if physicians applied well-validated clinical decision support rules that help sort out who should have a study and who should not. Most physicians think only about the radiation dose of the single study they are ordering and do not consider the radiation exposure that individual may get over a more prolonged period.
The numbers of CT scans have been rising at alarming rates over the past decade, often without a concomitant increase in diagnostic yield. A recent study on advanced imaging studies in emergency rooms (Korley 2010) showed that between 1998 and 2007 the rate of CT or MRI for injury-related conditions increased from 6% to 15% but the prevalence of life-threatening conditions increased only from 1.7% to 2.0%.
And in the Medicare population, the use of CT angiography of the head/neck rose 827% between 2002 and 2007 (Friedman 2010). And we are seeing more and more coronary CT angiograms in chest pain patients (though note that a negative coronary CT angiogram does have the potential to avoid the layering of testing noted above). Also becoming popular is the triple rule out CT (rule out coronary artery occlusion, aortic dissection, pulmonary embolus).
CT scanning in pediatrics remains a key issue. Though one study showed that CT utilization as a percentage of cross-sectional imagingstudies has decreased steadily since 2003 in pediatric facilities acrossNorth America (Townsend 2010), studies presented at the Pediatric Academic Societies (PAS) 2010 Annual Meeting (Hoyle 2010) demonstrated that pediatric head CT scans for trauma continue to be overordered and that observation of children with head trauma who lack red flags can often result in avoidance of unnecessary CT scanning. Moreover, a significant number of pediatric trauma patients who receive CT scans at referring hospitals before transfer to a level I pediatric trauma center require duplicate scans of the same anatomical field(s) after transfer, exposing them to increase potential clinical risk and cost (Chwals 2008).
Nationally, the Image Gently campaign has focused both on reducing the frequency of unnecessary exposures to ionizing radiation in children and to using lower doses of radiation when such studies must be done. In New York, as part of the Image Gently campaign, the Department of Health has made available an informational pamphlet for parents on imaging in their child and a medical imaging record card. We find that brochures like these also helps address some of the consumer demand for CT scans. When a physician provides a family with these as he/she is discussing the benefits and risks of various imaging modalities (or the benefits and risk of simply observing without imaging), families tend to be more understanding of approaches that do not involve CT scanning.
The FDA completed its investigation of last years rash of radiation overdoses from brain perfusion CT scans and concluded there was no equipment malfunction but rather that improper use of the systems had led to the overdoses. Nevertheless, they are working with the imaging manufacturing industry to improve design and functionality of imaging equipment, including development of adequate warnings for techs and radiologists when a patient is being exposed to higher than normal levels of radiation.
Tracking of cumulative radiation dosage is an equally important goal. As we develop electronic medical records, particularly with interoperability so that data can be exchanged across multiple hospital systems, free standing units and offices, a longitudinal record of a patients cumulative radiation exposure may be possible. An article just out (Cook 2010) describes a methodology for extracting radiation dose from those systems where dose is stored in an image-based dose sheet. Such might be used to get at least a partial cumulative dose record for patients as we wait for more proactive solutions in the future.
One of the most important strategies in reducing the frequency of unnecessary CT scans is letting your physicians know how often they order them (audit and feedback). Typically, when we provide this data we see considerable variation in ordering rates by individual provider. When they see how they compare to their peers and discuss the issue at departmental QI meetings, we usually see a subsequent reduction in unnecessary testing. One report noted that pediatric emergency room physicians were more likely to order CT scans on children than adult emergency room physicians (Sullivan 2008), a somewhat unexpected finding.
Making providers aware of the radiation dose exposure of individual tests as well as cumulative dosing may also be helpful. There are a couple web-based tools available for calculating radiation risk and/or radiation dose. One is Xrayrisk.com. The other is a pediatric CT Effective Dose and Cancer Risk Estimator developed by Alessi and Phillips (Alessi 2010). An excellent commentary on how to discuss the radiation hazard of CT scanning with patients (and our obligation to do so) was recently published in JAMA (Baerlocher 2010).
Use of clinical decision support rules is a good way to minimize the number of unnecessary CT scans. In our March 2010 Whats New in the Patient Safety World column CATCH: New Clinical Decision Rule for CT in Pediatric Head Trauma we discussed several rules that aid the decision about performing CT scans of the head in patients with minor head trauma. These include the Canadian CT Head Rule (Stiell 2001), the New Orleans Criteria (Haydel 2000) and the CHIP Prediction Rule (Smits 2007) for adults and CATCH (the Canadian Assessment of Tomography for Childhood Head Injury), for children with minor head injury (Osmond et al 2010). A recent cost-effectiveness analysis for use of these rules in minor head injury (Smits 2010) showed that use of these rules can produce substantial cost savings.
In our August 2009 Whats New in the Patient Safety World column Imaging for Acute Abdominal Pain we discussed multiple issues regarding imaging for acute abdominal pain and noted that a conditional strategy (ultrasound followed by CT only if the ultrasound is negative) could cut CT use by up to 50% and appears to be quite accurate, safe, efficient and economical and avoids some of the potential adverse effects of CT scanning.
And always keep in mind that there are risks to imaging beyond the radiation danger. Any time IV contrast is utilized there is a danger of contrast-induced nephropathy. In fact, a recent study (see Joelving 2010 reporting on a study by Mitchell et al.) noted that with spiral CT scanning to rule out pulmonary emboli, you are actually more likely to cause contrast-induced renal damage than to diagnose pulmonary emboli. In that prospective study of 175 ED patients who had CT for suspected pulmonary embolism, 9% were diagnosed with pulmonary embolism and received anticoagulation but 15% developed contrast-induced nephropathy.
The other significant risk often seen in CT scanning, particularly in pediatrics, is that related to sedation administered for the scan. We discussed that extensively in our May 25, 2010 Patient Safety Tip of the Week Propofol Issues.
So what should your organization be doing? We recommend the following as a start:
Einstein AJ, Weiner SD, Bernheim A, et al. Multiple Testing, Cumulative Radiation Dose, and Clinical Indications in Patients Undergoing Myocardial Perfusion Imaging. JAMA. published online Nov 15, 2010; (doi:10.1001/jama.2010.1664)
Korley FK, Pham JC, Kirsch TD. Use of Advanced Radiology During Visits to US Emergency Departments for Injury-Related Conditions, 1998-2007. JAMA 2010; 304(13): 1465-1471
Friedman DP, Levin DC, Rao VM. Trends in the Utilization of CT Angiography and MR Angiography of the Head and Neck in the Medicare Population.. J Amer Coll Rad 2010; 7(11): 854-858
Townsend BA, Callahan MJ, Zurakowski D, Taylor GA. Has Pediatric CT at Children's Hospitals Reached Its Peak? Am. J. Roentgenol., May 2010; 194: 1194 1196
Hoyle B. CT Scans Overused in Emergency Assessment of Pediatric Head Trauma? Medscape Medical News. May 12, 2010
Chwals WJ, Robinson, AV, Sivit CJ, et al. Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure. J Pediatr Surg 2008; 43(12): 2268-2272
The Image Gently Campaign.
NYSDOH. What Parents Should Know About CT Scans for Children: Medical Radiation Safety
My Childs Medical Imaging Record
Cook TS, Zimmerman S, Maidment ADA, et al. Automated Extraction of Radiation Dose Information for CT Examinations. J Amer Coll Rad 2010; 7(11): 871-877
Sullivan MG. Pediatric Physicians More Likely to Order Head CT Scans. ACEP News. August 2008
CT Effective Dose and Cancer Risk Estimator
Alessi A, Phillips GS. A pediatric CT dose and risk estimator. Pediatric Radiology 2010; 40(11): 1816-1821
Baerlocher MO, Detsky AS. Discussing Radiation Risks Associated With CT Scans With Patients. JAMA.2010;304(19):2170-2171. doi:10.1001/jama.2010.1591
Stiell IG, Wells GA,Vandemheen K, et al for the CCC Study Group. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357: 139196
Haydel MJ, Preston CA, Mills TJ, et al. Indications for Computed Tomography in Patients with Minor Head Injury. N Engl J Med 2000; 343: 100-5
Smits M, Dippel DWJ, Steyerberg EW, et al.Predicting Intracranial Traumatic Findings on Computed Tomography in Patients with Minor Head Injury: The CHIP Prediction Rule. Ann Intern Med. 2007; 146: 397-405
Smits M, Dippel DWJ, Nederkoorn PJ. Minor Head Injury: CT-based Strategies for ManagementA Cost-effectiveness Analysis. Radiology 2010; 254: 532-540
Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. Can. Med. Assoc. J., Feb 2010; early release published February 8, 2010 doi:10.1503/cmaj.091421
Joelving F. Contrast-induced nephropathy may be common after chest CT. By Reuters Health October 1, 2010
November 30, 2010
SURPASS: The Mother of All Checklists
Regular readers of this column know were strong advocates of using checklists. See our January 20, 2009 Patient Safety Tip of the Week The WHO Surgical Safety Checklist Delivers the Outcomes and our September 23, 2008 Patient Safety Tip of the Week Checklists and Wrong Site Surgery.
Now the results of implementation of the most comprehensive checklist we have ever seen, the SURPASS (SURgical PAtient Safety System) checklist, have been published (de Vries 2010a). The SURPASS checklist, which covers almost every process from the preadmission phase through the post-discharge period, was implemented at 6 Netherlands hospitals. Though a randomized controlled methodology was not feasible, a pre/post-implementation comparison methodology was used with a comparable control group being 5 other high-performing Netherlands hospitals. At the intervention hospitals, the total number of complications per 100 patients decreased from 27.3 to 16.7 and in-hospital mortality decreased from 1.5% to 0.8%.
Youll recall from our January 20, 2009 Patient Safety Tip of the Week The WHO Surgical Safety Checklist Delivers the Outcomes that mortality at 30-days post-op decreased from 1.5% before introduction of the WHO checklist to 0.8% after and the rate of any complication decreased from 11% to 7% (Haynes 2009).
So how does this differ from the results of implementing the WHO Surgical Safety Checklist? Probably the biggest difference was that all the hospitals in the Netherlands study were ones already performing at high levels. The other is that the SURPASS checklist is far more comprehensive and covers the entire surgical experience for a patient, not just the immediate perioperative period. Of course, some might argue, that comparable results were attained just using the shorter WHO surgical safety checklist so why should we use the much longer SURPASS checklist? Youll have to answer that yourselves but when we look at all the important items included on the SURPASS checklist, wed certainly opt for that.
Keeping with good design of checklists (see below), SURPASS is really a series of much shorter checklists, each of which contains items that could be easily overlooked if one were counting on memory alone. Also, it does not contain many items that would seldom be overlooked. Each component checklist requires signing off (and dating) by the appropriate person(s).
A good flowchart of the surgical process with notation of where each checklist is used is available on the SURPASS website. The SURPASS checklist begins on the day prior to surgery. Not only does it prompt to check that all the instruments, equipment and implants that will be needed are present but it also prompts a double check that all information in the OR schedule is correct (requiring discussion with the surgeon if there is any doubt).
Next is a preoperative checklist to be completed by the physician on the ward before the patient is transported to the surgical holding area. Here the physician (if different that the surgeon) must acknowledge that he/she has seen the patient and that all necessary clinical materials, including all lab and imaging studies, are available and that all relevant recommendations from consultants and anesthesiology have been carried out. This is particularly important since we have seen cases where a consultant orders a test and the surgeon, anesthesiologist, and consultant all think the test was reviewed by one of the others and no one actually reviews that test result. The physician also ensures that medications are ordered (eg. prophylactic antibiotics) and that anticoagulants have been discontinued if appropriate. It also prompts the physician to schedule an ICU bed if necessary.
A separate checklist for the surgeon is to be completed on the ward prior to transport to the surgical holding area. This one acknowledges that the surgeon has seen the patient and obtained informed consent, that all the data and information on the OR schedule is correct, and that he/she has discussed with the patient and marked the operative site. It also has items regarding comorbidities and allergies in those cases where an anesthesiologist will not be involved.
The anesthesiologist is also to see the patient on the ward prior to transfer to the holding area. His/her checklist reiterates many of the items on earlier checklists (all clinical and lab results, consultant recommendations, medications, allergies, etc.). He/she confirms that the completed informed consent is in the chart and orders any necessary premedications. He/she discusses with the patient the anesthesia technique planned and any alternatives.
Similarly, prior to transport to the holding area, the ward nurse completes a checklist. This one includes assessments for decubiti, falls, delirium (we love it! Wish US hospitals would do it!), and nutrition. The nurse preps the patient according to protocols and ensures that orders and clinical information are in the chart. She/he also checks that appropriate identification tags/bracelets are on the patient and removes dentures, etc. Lastly, the nurse confirms that the physicians checklist has been completed.
Next, in the OR the time out is done with the surgeon, anesthesiologist, anesthesia assistant, and operating assistant as a group. It contains most of the same items we would do under Universal Protocol or the WHO surgical safety checklist (correct patient, procedure, site, implants, prophylactic antibiotics given, patient positioning, presence of imaging studies and blood products, anesthesia equipment, instruments, etc.).
On completion of the surgery another series of checklists is completed prior to transfer to the post-op recovery area, One for the surgeon includes instructions regarding fees, tubes, drains, and other post-op needs. One for the anesthesiologist includes detains about fluid management, analgesics and other medications, ventilation, oxygen, and clinical and laboratory monitoring parameters.
Next is one completed by the anesthesiologist or intensivist prior to transfer to the ward or ICU. This confirms that the patient has met criteria for discharge from the PACU and includes communication to the next set of caregivers regarding analgesics, other medications, fluids, diet, oxygen, monitoring parameters, wound care, and any other special instructions.
The penultimate checklist is done prior to discharge. It has a section to indicate that the physician has discussed the pathology with the patient, plus instructions regarding wound care, drains/tubes, diet, anticoagulants, etc. It ensures that medication reconciliation takes place and that all followup appointments have been arranged and that the discharge summary has been completed and sent to the next caregiver.
The final checklist is completed by the ward nurse. It confirms that the above checklist was completed by the physician and repeats most of the same elements that the physician completed at discharge.
The SURPASS checklist is not an easy implementation. It took, on average, 6 to 9 months to implement at each hospital. De Vries and colleagues previously discussed the development and validation of the SURPASS checklist (de Vries 2009).
Some other very good articles on checklist design are available (Verdaasdonk 2008, Verdaasdonk 2009). Our July 6, 2010 Patient Safety Tip of the Week Book Reviews: Pronovost and Gawande had some key points on checklist design from Atul Gawandes book The Checklist Manifesto: How to Get Things Right. The Verdaasdonk articles also reference an excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists. We also discussed checklist design and use in our September 23, 2008 Patient Safety Tip of the Week Checklists and Wrong Site Surgery.
Other comprehensive checklists have been developed for specific surgical settings. Use of a 28-item structured checklist (Verdaasdonk 2008) addressing problems with laparoscopic equipment resulted in a 53% reduction of incidents related to such equipment. And Lingard et al (Lingard 2008) used a checklist to structure short team briefings and documented both reduction in the number of communication failures and other utility of the intervention.
Individual checklists generally take only minutes to complete. The beauty of checklists is that they are both simple and save time in the long run. Even the 28-item laparoscopic checklist in the Verdaasdonk article took only an average of 3.3 minutes to complete. Though they did not specifically measure it, we suspect that there was far more time savings on the back end, i.e. the time saved by avoiding equipment problems probably far exceeded the 3.3 minutes taken on the front end.
As per our prior articles on checklists, we do advocate doing periodic audits of compliance with the checklists in toto and compliance with individual components of the checklist. In the SURPASS study, complication rates were generally lower in those cases where compliance with the checklists were higher.
The SURPASS checklist does help ensure that evidence-based care gets implemented. A previously reported study showed the use of the SURPASS checklist leads to better compliance with regard to the timing of antibiotic prophylaxis administration (deVries 2010b). But its real value is probably in fostering teamwork, communication, and handoffs. Perhaps the biggest debate in both the SURPASS study and the WHO study is whether the striking improvements are attributable to use of the checklist per se or to the change in culture that accompanied use of the checklist. Again, to that debate we say who cares?. If merely using a checklist results in such powerful improvement in the culture of safety and promotion of better communication and teamwork, use it!!!
Checklists are some of the most valuable tools we have available in quality improvement and patient safety. They are also the least expensive of all tools. But the ROI on checklists is incredibly high, both in human terms and financial terms.
de Vries EN, Prins HA, Crolla RMPH, et al. for the SURPASS Collaborative Group.Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med 2010; 363: 1928-1937
the SURPASS checklist
Haynes AB, Weiser TG, Berry WR, et al. for the Safe Surgery Saves Lives Study Group. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. Online First January 14, 2009 (DOI: 10.1056/NEJMsa0810119), in Print January 29, 2009
flowchart of the processes in SURPASS
de Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care 2009;18:121-126
Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc (2009); 23: 715726
Verdaasdonk EG, Stassen LP, Hoffman WF, van der Elst M, Dankelman J. Can a structured checklist prevent problems with laparoscopic equipment. Surgical Edoscopy 2008; 22: 2238-2243 (accessed online 9/22/2008) http://www.springerlink.com/content/1845j684574501v2/
Gawande A. The Checklist Manifesto: How to Get Things Right. Metropolitan Books 2010
Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use
of Emergency and Abnormal Checklists. January 2006.
Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
de Vries EN, Dijkstra L, Smorenburg SM, et al. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Safety in Surgery 2010; 4: 6
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
Several articles in the past couple months have pointed out wrong-site surgery continues to occur and offer some useful insights into contributing factors.
A study using self-reported adverse events from a Colorado physicians malpractice insurance database (Stahel 2010) highlights the continued occurrence of wrong-patient and wrong-site occurrences but also has some interesting revelations. Over a 6 year period they found 25 cases of wrong-patient procedures and 107 cases of wrong-site procedures, with patient harm occurring in 20% and 36% respectively.
Root cause analyses were available on most cases. Not surprisingly, errors in communication were highly prevalent in both categories, though more frequent in the wrong-patient cases. On the other hand, errors in judgment were much more common in the wrong-site cases. Failures in the time-out process were significant in the wrong-site cases but not the wrong-patient cases.
Perhaps the most revealing finding in the study was the contributory roles played by physicians in specialties outside the OR, i.e. physicians other than surgeons and anesthesiologists. Weve long known that wrong-site procedures outside the OR are frequent (in our Patient Safety Tip of the Week November 25, 2008 Wrong-Site Neurosurgery we noted that chest tubes inserted on the wrong side was the most frequent wrong-site occurrence in New York State in the past). But the Stahel paper notes how often events such as mislabeling pathology specimens, mixups in medical records or imaging studies or lab reports contributed to the adverse events even inside the OR. The study highlights the importance of the time-out in multiple venues of patient care where correct identification of patients and clinical information is critical. While we have always advocated time-outs prior to any invasive procedure (eg. thoracenteses, paracenteses, lumbar punctures, etc.), the same sort of diligence should be applied in places like the pathology lab. See our Patient Safety Tips of the Week for October 9, 2007 Errors in the Laboratory where we discussed pathology specimens being mixed up and November 16, 2010 Lost Lab Specimens for examples of vulnerable laboratory processes.
It has long been recognized that multiple surgeries are a risk factor for wrong-site surgery. A recent case at Yale-New Haven Hospital (Bailey 2010) illustrates how such cases can happen. A motor vehicle accident victim had fractures of the right ankle and pelvis and was taken to the OR for surgery on the right ankle. Two surgical residents discussing the case also noted the left leg was internally rotated and shorter than the right leg so decided that a skeletal traction pin should be applied to the left leg. However, after surgery on the right ankle was completed, the skeletal traction pin was applied mistakenly to the right leg. The investigation determined that no second timeout had occurred prior to the second procedure. Yale-New Havens protocol apparently required a second timeout only when a surgeon (or surgical team) performing the second procedure was not present during the initial timeout. They apparently subsequently modified their protocol to require a second timeout any time a second procedure is to be done, regardless of whether there have been changes in the surgical team or not.
A second case (Knight 2010) illustrates why verification of all clinical information during a timeout, not just verification of the site marking, is critical. In this case, a permanent marker was used to place an arrow, smiling face, and surgeons initials on the correct leg of a 2-year old undergoing femur surgery. However, when the patient arrived in the OR, there were markings on both legs (see photos in the article). It appears that the positioning of the legs had resulted in transfer of some of the marking to the other leg. Fortunately, the correct site was verified from clinical notes, the consent form, and imaging studies.
A third case received the most attention since it was published in the New England Journal of Medicine (Ring 2010). We applaud the surgeon involved in the case and the Massachusetts General Hospital for giving public attention to this case so that valuable lessons would be shared with the greater medical community. A patient scheduled for a trigger finger release instead received carpal tunnel release surgery. The root cause analysis demonstrated the typical cascade of events we usually see in cases with adverse outcomes, including communication errors, time pressures, distractions of multiple personnel, and failures to adhere to best-practice protocols.
The surgeon had several surgical cases scheduled that day, 3 major cases and then 3 he admittedly considered minor cases. The first two minor cases were carpal tunnel releases and the last case was the patient scheduled to have the trigger finger release. (Note that weve considered multiple simple surgeries to be as high or higher a risk for errors as a single complicated case. This is especially so in specialties where many cases typically get scheduled consecutively, for example ophthalmology or ENT. The larger number of patients involved, often with multiple charts and multiple imaging studies, increases the opportunity for mixups and the added time pressures may lead to shortcuts and workarounds.) Though the first minor case went well, the patient had some concerns about the injection of anesthetic that required additional time for the surgeon with that patient. The surgeon also was called away to translate for the preoperative preparation of the patient involved in the incident (she spoke Spanish, no interpreter was available, and the surgeon spoke Spanish). The surgeon noted that a nurse had marked the arm on which the surgery was planned (apparently hospital protocol at the time allowed nurses to mark the site). The surgeon then returned to perform uneventful surgery on the second case. But the last (third) case was moved to another room because several other cases in the OR were running late. The latter change also resulted in a change in OR personnel so that the nurse who had performed the preoperative evaluation was no longer involved in the case. Because of that delay, the surgeon also went to perform a consultation elsewhere and then also had to further console patient #1 about the anesthetic injection issue. As the last case was being prepared for in the OR, a nurse had to search for a tourniquet and fell behind on her documentation. The site marking was washed off by the preparation of the arm with soap, alcohol and providone-iodine. The surgeon spoke to the patient in Spanish. The nurse mistakenly thought this was the timeout. Hence, no formal timeout took place. There was also a nursing change mid-procedure. The surgeon performed a carpal tunnel release and only recognized the error about 15 minutes later while dictating the op report.
Once the error was recognized, the response was prompt and appropriate, with disclosure and apology (see our June 22, 2010 Patient Safety Tip of the Week Disclosure and Apology: How to Do It and our November 2010 Whats New in the Patient Safety World column IHI: Respectful Management of Serious Clinical Adverse Events). The hospital did its root casue analysis and made multiple system changes. Nursing is no longer responsible for marking the surgical site (that is the responsibility of the surgeon) and alcohol-based solutions that might erase the ink are no longer allowed. The timeout process was improved to meet the Join Commissions updated Universal Protocol and educational sessions for all staff made it clear the timeout verification process is an active rather than passive one and should involve the patient where possible. Importantly, the nurse may not give the scalpel to the surgeon until the timeout has been completed. The culture of safety means the entire team is responsible and the verification and Universal Protocol need to be followed, with surgeons taking the lead.
Finally, the Pennsylvania Patient Safety Authority has continued to provide its valuable contributions to help avoid wrong-site surgery. Youll recall the PPSA has been providing quarterly updates on wrong-site surgery now for several years. They continue to see about a case per week reported despite all the knowledge we have accumulated for preventing wrong-site surgery. This month in their quarterly update on wrong-site surgery they provide several principles and supporting evidence for each.
First, the correct site of the procedure should be specified at the time the case is scheduled. See our August 2010 Whats New in the Patient Safety World column Surgical Case Listing Accuracy for a discussion on the current pitfalls in that process. PPSA notes that about 5% of wrong-site surgeries involve errors in the scheduling process. The next two principles involve ensuring that the correct operation and site be indicated on the history & physical and the informed consent, respectively. And the next one is that everyone involved should review the information on the schedule/booking, H&P, informed consent, and any other reports with the diagnosis and that any discrepancies need to be reconciled with the surgeon.
Another principle, which we consider very important, is that the surgeon have any supporting information uniquely available in the office notes at the surgical facility on the day of surgery. Our June 5, 2007 Patient Safety Tip of the Week Patient Safety in Ambulatoy Surgery noted that the quality of the medical records is often not as good in ambulatory settings. The facility medical record is often scant and the physician often brings in his/her office notes that are unofficial as far as the facility is concerned. Often critical information is in the physician office record and never appears in the facility medical record. It is therefore incumbent upon the facility and entire team to ensure the adequacy of the medical record and all documentation prior to the procedure.
The next principle is that all the information that should be used to support the correct patient, operation, and site, including the patients or familys verbal understanding, should be verified by the nurse and surgeon before the patient enters the OR.
The principle that 2 unique patient identifiers are required in all cases is, of course, a Joint Commission requirement. Note in the Stahel paper noted above there were cases of wrong patient surgery involving patients who had identical first and last names.
This next principle is also very important: any discrepancies must be resolved by the surgeon, based on primary sources of information, prior to the patient entering the OR. Weve seen or heard of several cases where discrepancies were resolved based on the surgeons memory where that memory turned out to be wrong.
Several principles related to site marking follow, including marking with the intials of the surgeon and marking done in conjunction with verification of all supporting information plus the alert patients (or familys) understanding, and verified also by the circulating nurse on moving the patient into the OR.
The next several principles apply to the timeout and are mentioned in the NEJM case above: verification procedure should be an active one rather than a passive one and all potentially distracting noncritical activities be suspended during the timeout and verification procedure. It is critical that all questions during the timeout verification procedure be phrased in a manner that requires and active answer. Never should you assume that no answer means concurrence. And all involved should be verifying that they are verifying information from relevant documents, not just second-hand information. And the site marking needs to be clearly visible in the prepped, draped field during the timeout. And all this must take place in an environment where all staff are encouraged to speak up and voice any concerns. If there are any concerns, the surgeon must resolve those concerns based on primary sources of information to the satisfaction of all team members.
The principle that separate timeouts be performed for separate procedures, including anesthetic blocks, with the person performing that procedure was noted earlier and needs to apply to all procedures, not just ones performed by different providers.
Its humbling when wrong-site surgery can occur at some of our most respected hospitals. But these occurrences make it clear that we must have both a culture of safety and specific system interventions in place to ensure that such events do not occur in our organizations. We highly recommend that you read the whole PPSA article and take the principles outlined in the PPSA quarterly update, put them in a checklist format, and use that checklist to perform random audits on cases at your facility. Note that requires someone physically being present to observe some portions of the entire workflow or you have the means of video recording of portions of that workflow, such as the timeout occurring in the OR itself. That is critical to understanding whether the timeouts are truly performed in an active, rather than passive, format and that all staff involved truly feel empowered to stop a procedure at any time they have any concerns or discomfort.
Some of our prior columns related to wrong-site surgery:
Patient Safety Tip of the Week columns:
September 23, 2008 Checklists and Wrong Site Surgery
June 5, 2007 Patient Safety in Ambulatoy Surgery
March 11, 2008 Lessons from Ophthalmology
September 14, 2010 Wrong-Site Craniotomy: Lessons Learned
November 25, 2008 Wrong-Site Neurosurgery
January 19, 2010 Timeouts and Safe Surgery
June 8, 2010 Surgical Safety Checklist for Cataract Surgery
Whats New in the Patient Safety World columns:
Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era. Analysis of a Prospective Database of Physician Self-reported Occurrences. Arch Surg.2010; 145(10): 978-984
Bailey M. Doctor Operates On Wrong Leg. New Haven Independent November 2, 2010
Knight DMA, Wedge JH. Marking the operative site: a lesson learned.
CMAJ 2010 182: E799.
Ring DC, Herndon JH, Meyer GS. Case Records of the Massachusetts General Hospital.
Case 34-2010 A 65-Year-Old Woman with an Incorrect Operation on the Left Hand. N Engl J Med 2010; 363:1950-1957
Pennsylvania Patient Safety Authority. Quarterly Update: The Evidence Base for Best Practices for Preventing Wrong-Site Surgery. Pa Patient Saf Advis 2010 Dec;7(4):151-4.
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
The UK National Patient Safety Agency has just issued a rapid response report on preventing fatalities from medication loading doses. This is a medication safety issue that has long flown under everyones radar. Problems with loading doses occur at every institution we have ever worked with, yet there is almost nothing in the literature highlighting this problem.
Loading doses are given when one wants to get the serum and/or tissue level of a drug up to achieve a therapeutic effect rapidly. Probably the best example is the loading dose of phenytoin in a patient with status epilepticus. In such cases there is an immediate urgent need to stop the patients seizures and prevent recurrence. It would take several days to get therapeutic levels of phenytoin if the patient were simply started on a typical oral maintenance dosage.
While the NPSA alert identified incidents in their databases involving loading doses of many medications, four medications (warfarin, amiodarone, digoxin, and phenytoin) really stuck out. These accounted for 36% of all incidents and 50% of all those causing moderate or severe harm.
In 41% of the incidents, the loading dose was either ordered or administered incorrectly. In another 24% it was either omitted or delayed. In a further 11% the loading dose was either repeated or continued incorrectly as the maintenance dose and in 8% the maintenance dose was prescribed at the wrong time (eg. too soon after the loading dose). They also noted that handovers and transitions of care were also vulnerable to missed communications regarding loading/maintenance doses.
The NPSA review included a literature search using keywords such as loading and error and had remarkably little success in finding published cases. We tried the same in a number of databases and different search terms and were similarly unsuccessful. In a case that received a lot of attention a few years ago, a patient died when inadvertently given 8000 mg. of IV Dilantin. An ER physician ordered a loading dose of 800 mg. IV for a patient with seizures but the nurse mistakenly thought it was 8000 mg. The nurse apparently had to use 32 vials of phenytoin to make up that amount! But not many other cases turned up.
However, coincidentally, the FDA just did a thorough review of both intravenous phenytoin and fosphenytoin last month and includes statistics about adverse effects and does cite cases of hypotension, bradycardia, cardiovascular collapse, and death. That panel was convened because of safety concerns surrounding IV phenytoin. However, the panel voted unanimously to keep IV phenytoin on the market, in part because of a current shortage of fosphenytoin and no good current alternative drugs for phenytoins indications.
One of the first questions we always ask when doing a root cause analysis of an event related to a procedure is did the patient need the procedure in the first place?. Well, in these cases we should ask does the patient really need a loading dose?
The answer for warfarin (coumadin) appears to be no. The evidence base was summarized recently in an ICSI Guideline: Venous Thromboembolism Diagnosis and Treatment and a systemic review (Heneghan 2010). Both conclude that there is no advantage to loading patients with a 10 mg. dose compared to starting with 5 mg. daily and they discourage use of the 10 mg. dose, particularly in elderly patients. The 10 mg. dose may or may not get the patient to a therapeutic INR faster (depending on which study you read) but may also be associated with early overanticoagulation and there is even some theoretical concern that the loading may actually promote the early hypercoagulability sometimes seen during warfarin initiation.
For phenytoin (Dilantin) the answer depends on the clinical circumstances. Obviously for true status epilepticus a loading dose is appropriately indicated. But for a patient who has had a single seizure (unless that seizure happens to occur during neurosurgery), a loading dose is probably not necessary. The gray zone would be in the patient who has had a flurry of several seizures but does not meet the definition of status epilepticus.
The rate of administration of IV phenytoin (and IV fosphenytoin) is the critical factor in producing hypotension, bradycardia or cardiovascular collapse. The rate is not to exceed 50 mg/min. in adults (1-3 mg/kg/minute in neonates) and should be by a slow IV push, not an infusion. That means that for a typical loading dose in an adult (1000-1500 mg), the physician would need to spend 20-30 minutes administering the drug. Over the years weve seen corners cut and either the rate would be accelerated or an IV infusion would be used. Some of that is because many neurologists have not seen significant cardiac side effects from IV phenytoin. But those of us who remember giving IV phenytoin to cardiac patients (once upon a time it was used more frequently as a second- or third-line antiarrhythmic agent) recall watching blood pressures bottom out as we increased rates of the IV push. The FDA review notes that the majority of cardiovascular deaths (for both IV phenytoin and fosphenytoin) occurred in adults and at recommended doses. Most had pre-existing cardiovascular disease.
Another key issue with phenytoin is use of the wrong dilution technique. It is supposed to be given in normal saline, not glucose solutions. Note also that intravenous phenytoin has been associated with the purple glove syndrome (FDA 2010), a rare but serious condition. That was actually the primary reason for the recent FDA safety review.
Amiodarone is now a widely used antiarrhythmic drug that has peculiar volume of distribution and pharmacokinetics. Thus, it is typically given in high doses for the first week or so, then tapered down to much lower maintenance doses. Of course, the other problem is that it has a very long half-life and remains in the body for a long time after discontinuation. The NPSA alert describes a patient who died after taking a loading dose of amiodarone for 12 months rather than what should have been a much lower maintenance dose. While amiodarone is typically initiated in-hospital, the relatively long duration of the loading period means that most patients are discharged from the hospital before the transition to the maintenance dose takes place. Hence, the potential for errors during the handoffs from one venue to another become another challenge.
Digoxin toxicity is, fortunately, much less common today primarily because we use so little digoxin. Whereas previously it was used in CHF patients for its inotropic actions, its primary use today is for its chronotropic effects (mainly to slow the heart rate in atrial tachyarrhythmias). But it is for that chronotropic effect that the loading dose is most often necessary. Digoxin has one of the narrowest therapeutic ranges of all the drugs we use and is extremely susceptible to development of toxic manifestations based on renal function and electrolyte disturbances.
Loading doses may be especially problematic when staff are unfamiliar with the drug involved. ISMP described a case in 2000 where the glycoprotein IIb/IIIa inhibitor Integrilin was given inadvertently in too high a loading dose in a patient forced to stay in a surgical ICU because the CCU was full. Unfamiliarity of the staff in that unit with the nuances of Integrilin use played a role. It is important to ensure that all staff (nursing, pharmacy, and physicians) be provided adequate information about various medications, especially those considered to be high risk ones. This case illustrates a point we have made several times: while we typically develop order sets for those conditions we most commonly encounter, sometimes it makes sense to also develop order sets for those that are rarely encountered but could be problematic to those unfamiliar with the condition.
Technological solutions are obvious potential means to avoid such errors. But does CPOE actually reduce the chance of errors with loading doses or could it paradoxically increase that risk? Weve seen some pretty clunky IT systems that are not particularly user-friendly when it comes to ordering medications. That is especially so when the order is a complex one in which different doses of a drug are being given on different days, as is the case with loading doses followed by maintenance doses. Considerable confusion may occur when entering such orders, whether directly entered by the physician or entered by a nurse or pharmacist. We have seen instances where the loading dose of a drug gets continued every day or ones where the patient gets both the loading dose and maintenance dose on the same days. Theoretically, use of standardized order sets or protocols (whether paper or electronic) may help avoid such errors but such have not specifically been studied for drugs with loading doses.
The other problem, of course, is that clinical decision support tools that can make CPOE and pharmacy computer systems safer are still suboptimally used. Many current systems do not provide dose range alerts that would flag a relatively high dose of a medication for verification. Also, most current systems do not require an indication field be filled out for each drug. A good system would require input of the indication, with a check box or drop down list where loading dose could be indicated (and the system programmed to not continue loading doses beyond the specified time period).
We concur with the NPSA recommendations that each facility should:
Loading doses are an error-prone facet of the medication process that have been underrecognized but have the potential to cause significant patient harm. You should consider adding an initiative on loading doses to your medication safety program.
NPSA (UK). Rapid Response Report. Preventing Fatalities from medication loading doses. November 2010
Rapid Response Report
Patient died from 8GMs of Dilantin
Allnurses.com Jan 25, 2007 10:03 PM written by CraigBSN02
FDA. Joint Meeting of the Peripheral and Central Nervous System Drugs Advisory Committee and the Drug Safety and Risk Management Advisory Committee. November 3, 2010
ICSI (Institute for Clinical Systems Improvement). Health Care Guideline: Venous Thromboembolism Diagnosis and Treatment. February 2010
Heneghan C, Tyndel S, Bankhead C, et al. Optimal loading dose for the initiation of warfarin: a systematic review. BMC Cardiovascular Disorders 2010; 10:18
ISMP (Institute for Safe Medication Practices). Admitting "overflow" patients to units without proper expertise is a setup for errors. ISMP Medication Safety Alert Acute Care Edition 2000; October 4, 2000
December 21, 2010
More Bad News About Off-Hours Care
Each year as we wish our readers Happy Holidays we always remind them to be extra vigilant for patient safety issues over the holidays. Nights and weekends are times prone to patient safety incidents and many of the factors that come into play over holiday vacations may further increase the risk of such incidents.
Weve published several columns highlighting the untoward events that tend to occur on nights and weekends and some of the reasons why:
But in the past month or so we have seen a flurry of articles further demonstrating the occurrence of adverse outcomes off-hours.
The abstract of a study presented at the recent American Society of Neprhology annual meeting (Sakhuja 2010) showed that patients with end-stage renal disease (ESRD) admitted on weekends were 17% more likely to die in the hospital than those admitted on weekdays, even after adjustment for other factors. Time-to-dialysis was also 0.29 days longer in patients admitted on weekends.
Stroke fatality rates are also higher for patients admitted on weekends compared to weekdays (Fang 2010). A number of previous studies had also demonstrated increased stroke mortality in patients admitted on weekends (and some also demonstrated increased mortality for those admitted on weekday nights). But the new study was also able to determine factors related to stroke severity and quality of care measures. They did show that stroke severity probably contributes, since more patients with moderate or severe strokes were admitted on weekends. But even after adjustment for stroke severity and a number of other clinical and demographic factors, the stroke fatality rate was 17% higher for those patients admitted on weekends (remarkably similar to the 17% higher mortality rate for ESRD patients noted above). And several key measures of quality of care (eg. percentage receiving neuroimaging, time to neuroimaging, percentage admitted to stroke units, percentage receiving dysphagia testing) were no different in those admitted on weekends.
A study presented at the 2010 American Heart Association annual scientific sessions (Penn Medicine press release) also showed that the quality of hospital CPR is worse at night. Mean chest compressions per minute were fewer in CPR administered during nighttime hours and chest compressions were stopped for longer intervals before and after defibrillation attempts. The authors note a number of factors that might contribute to this, including staff fatigue, lower staffing levels, lack of supervision from supervising physicians, etc. They offer helpful suggestions about potential ways to improve on CPR, such as simulations, use of CPR devices that provide real-time feedback, debriefings, and more supervising physician involvement.
In a recent study (Wu 2010) the incidence of neonatal encephalopathy was higher for babies born at night (defined as between 7:00 PM and 6:59 AM) and highest for those born between 10:00 PM and 4:00 AM. Two previous studies using large national databases have looked at the influence of time of day and day of the week on perinatal outcomes. Previously, a Scottish study (Pasupathy 2010) showed about a 30% increased neonatal mortality for full-term deliveries taking place at all times other than Monday thru Friday from 9 AM to 5 PM. This was largely explained by an increased number of deaths attributed to intrapartum anoxia. After excluding elective Caesarean sections, the difference was attenuated but a significant association between time of delivery and outcome persisted. A Dutch study (de Graaf 2010) found increased perinatal mortality and an increase in a combined perinatal adverse outcome measure in nontertiery hospitals during the evening and night and in tertiary hospitals at night. On the other hand, a previous study (Caughey 2008) showed no difference in neonatal morbidity and mortality by time of day in neonates delivered at term and a study of cesarean sections (Bailit 2006) showed no increase in complications related to time of day.
A recent paper on delays in brain death examinations and the impact on organ donation (Lustbader 2010) showed a 26% weekend drop in brain death examinations and a longer interval between examinations where 2 examinations were required. Both led to a substantial drop in the number of organs available for donation.
Even primary care settings are prone to patient safety incidents (Smits 2010) during off-hours. These authors found an incident rate of 2.4% for patients who had contact with their general practice cooperatives in the Netherlands. Though most incidents did not result in harm to patients, some did have consequences for patients such as additional testing or hospitalizations. Age of patients was significantly related to incident occurrence, with the rate increasing by 1.03 for each year increase in age.
The differences between the hospital during weekday daytime hours and the hospital at night and on weekends is striking. 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 highly error-prone, at night and on weekends.
In our July 20, 2010 Patient Safety Tip of the Week More on the Weekend Effect/After-Hours Effect we noted a study from the UK (Temple 2010) suggesting a physician component as well is part of the weekend effect. The study found the death rate at hospitals across England increased by 7% at weekends over the 2005-06 period. They ascribed the increased mortality rates on weekends to primarily two causes: (1) reliance on more junior physicians and (2) lack of specialist services. A systematic review and meta-analysis (Canallazzi 2010) found that there is an increased risk of death for patients admitted to an ICU over the weekend (about 8%) but not for those admitted at night. They suspect that organizational and staffing issues may explain the increased risk on weekends and note factors such as decreased physician-to-patient ratios, unavailability of board-certified intensivists, physician fatigue, and difficulty obtaining complex diagnostic tests as possible contributing factors.
But often it is the difference in non-clinical staffing that is a root cause. 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 ICUs on a weekend. Youll 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 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. Youll also see nurses giving directions to the increased numbers of visitors typically seen on weekends. They even end up doing some housekeeping chores. 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, InattentionOops! and May 4, 2010 More on the Impact of Interruptions).
One factor often overlooked is the impact of shift work. Both nurses and physicians often work in shifts where the time of day worked varies and it is clear that such practices may have a number of detrimental effects in any industry. A nice discussion of this was provided in an article by the BMA Scottish Junior Doctors Committee. Though that paper was aimed at the hours worked by residents, they discuss the implications of shift work in numerous industries and the potential impact on safety and the potential health implications. One statistic they quote is that the estimated risk of reported adverse incidents in industry increases to 6% on the second night shift, 17% on a third, and 36% higher risk on a fourth night shift worked (the corresponding numbers for consecutive day shifts are 2%, 7% and 17%).
Quality/safety-guru-turned-hospital-CEO David Shulkin, M.D. described what he saw when rounding on nights and weekends at his hospital (Shulkin 2008). He describes many of the same observations we have noted above. But he really stresses the value of doing those rounds off-hours. One of our most successful patient safety activities is our Patient Safety Walk Rounds but we still tend to do the bulk of those walk rounds during day shifts Monday thru Friday rather than at our most vulnerable times. Shulkin also stresses the importance of involving front line staff, clinical leadership and administration in addressing these vulnerabilities. And he developed a tool, the SWAN (Safety on Weekends And Nights) tool, that we highly recommend all hospitals should use. It is basically a checklist that looks at the various services and practices in your organization that have an impact on quality and patient safety at night and on weekends. It is a good exercise you should do with collective group of your hospitals clinical and administrative leaders. It can be a real eye opener!
What should you be doing at your organization? We suggest the following:
We have an incredibly long way to go in resolving the disparities in care we deliver between normal hours and off hours.
Sakhuja A, Kumar N, Nanchal RS, Dall AT, Kumar G. Weekend Admissions Predict Higher Mortality in Patiens with End Stage Renal Disease (abstract). American Society of Neprhology 2010; Annual Meeting 2010. J Am Soc Nephrol 2010; 21: 11A
Fang J, Saposnik G, Silver FL, Kapral MK for the Investigators of the Registry of the Canadian Stroke Network. Association between weekend hospital presentation and stroke fatality. Neurology 2010; 75: 1589-1596
University of Pennsylvania news release. Penn Study: Hospital CPR Quality Is Worse At Night. Findings Reveal Potential Cause of Lower Survival from Nighttime In-Hospital Cardiac Arrest. Nov. 14, 2010
Wu YW, Pham TN, Danielsen B et al. Nighttime delivery and risk of neonatal encephalopathy. American Journal of Obstetrics & Gynecology 2010; published online 12 November 2010
Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GCS. Time of birth and risk of neonatal death at term: retrospective cohort study. BMJ2010;341:c3498, doi: 10.1136/bmj.c3498 (Published 15 July 2010)
de Graaf J, Ravelli A, Visser G, Hukkelhoven C, Tong W, Bonsel G, Steegers E. Increased adverse perinatal outcome of hospital delivery at night. BJOG 2010; 17: 10981107
Caughey AB, Urato AC, Lee KA et al. Time of delivery and neonatal morbidity and mortality. American Journal of Obstetrics & Gynecology 2008; 199(5):496.e1-496.e5
Bailit JL, Landon MB, Thom E et al. The MFMU Cesarean Registry: Impact of time of day on cesarean complications.American Journal of Obstetrics & Gynecology 2006; 195(4): 1132-1137
Lustbader D, O'Hara D, Wijdicks EFM, et al. Second brain death examination may negatively affect organ donation. Neurology 2010;
Published online before print December 15, 2010, doi: 10.1212/WNL.0b013e3182061b0c Neurology December 15, 2010 WNL.0b013e3182061b0c
Marleen Smits M, Huibers L, Kerssemeijer B, et al. Patient safety in out-of-hours primary care: a review of patient records. BMC Health Services Research 2010, 10:335
Temple J. Time for Training. A Review of the impact of the European Working Time Directive on the quality of training. May 2010
Cavallazzi R, Marik PE, Hirani A, et al. ssociation Between Time of Admission to the ICU and Mortality: A Systematic Review and Metaanalysis.
Chest 2010; 138: 68-75
BMA Scotland. Shift-work, Rest and Sleep: Minimising the Risks
Discussion paper by the BMA Scottish Junior Doctors Committee
Shulkin DJ. Like Night and Day Shedding Light on Off-Hours Care. NEJM 2008; 358:2091-2093
Shulkin D. SWAN tool.
December 28, 2010
HAI's: Looking In All The Wrong Places
Progress on preventing surgical site infections (SSIs) and other healthcare-associated infections (HAIs) has been slow. But several new articles suggest maybe weve been looking in all the wrong places for solutions!
The January 2011 issue of Anesthesia & Analgesia has an article on the role of hand contamination of anesthesia providers as a risk factor for intraoperative bacterial transmission (Loftus 2011). Researchers at Dartmouth-Hitchcock did microbiological cultures of the IV stopcock set on the patient and of 2 sites on the anesthesia equipment from randomly selected OR cases (limited to first or second cases of the day) plus cultures from the hands of anesthesia providers. Overall, they identified bacterial transmission to the operative environment in 89% of cases and anesthesia providers were identified as the source in 12% of these cases. Transmission to the patient IV stopcock setup occurred in 11.5% of cases and anesthesia providers were identified as the origin in almost half (47%) those cases. Note that they were able to culture one or more pathogenic bacteria from 66% of provider hands before intraoperative patient care. Remarkably, this occurred despite 90% compliance with hand hygiene practices during the period of the study, suggesting that the effectiveness rather than the frequency of the hand hygiene techniques is of concern.
Other factors identified as independent predictors of environmental transmission included anesthesia provider supervising more than one room, first case of the day, patient age, and discharge to the ICU from the OR. The fact that anesthesia providers moving from one room to another may increase the rates of transmission certainly raises the likelihood that any healthcare worker moving from room to room may increase transmission rates. In some of our prior articles on the relationship between surgical duration and SSI rates (see our March 10, 2010 Patient Safety Tip of the Week Prolonged Surgical Duration and Time Awareness and our January 2010 Whats New in the Patient Safety World column Operative Duration and Infection), we have noted that OR traffic typically increases in longer duration cases. That likely increases the risk of bacterial transmission as well. As cases go on longer, foot traffic in and out of the OR increases, both as staff go on breaks or change shifts and as interruptions for questions, etc. begin to affect the surgeons and anesthesiologists. Long duration of surgery has long been known to be a factor associated with increased risk of surgical site infection and increased foot traffic may be one factor that increases the likelihood of surgical site infections (Lynch 2009).
The same group from Dartmouth-Hitchcock had previously demonstrated that such transmission was associated with increased patient mortality (Loftus 2008) and that use of a novel hand sanitation strategy dramatically reduced the intraoperative bacterial transmission and reduced healthcare-associated infections (Koff 2009). In the latter study, anesthesia providers were given a hand sanitation device to be worn and used in addition to the typical wall-mounted dispensers. Hourly hand decontamination events increased 27-fold. Contamination of the anesthesia work area and patient IV tubing dropped dramatically and HAI rate dropped to 3.8% compared to the 17.2% rate seen in controls.
An editorial accompanying the current article (Roy 2011) discusses the ubiquity of the bacterial slime we all carry and discusses documented cases of bacterial transmission from healthcare workers resulting in actual HAIs for patients. It raises many interesting issues like should all OR personnel routinely be cultured? and what would we do with the results?. They also point out we should be developing better disinfecting protocols for not only our anesthesia equipment but for the host of other equipment and toys we bring into the OR (stethoscopes, computer keyboards, cell phones, iPads, iPods, pagers, personal bags, etc.).
A second editorial (Hollman 2011) notes that anesthesia providers currently participate in tasks designed to reduce SSIs (eg. timely hanging of prophylactic antibiotics, maintenance of normothermia, etc.) but that SSI rates seem to have plateaued and we need better strategies to further reduce them. They call for improving the effectiveness of decontamination of the anesthesia work area and better hand hygiene practices. An editorial accompanying the Koff article (Hopf 2009) discusses the low rates for hand hygiene by anesthesiology providers in particular and some of the barriers that exist in the OR environment.
But surgical duration in the OR is not the only place to look when addressing SSIs and HAIs. A recent paper (Vogel 2010) showed that in-hospital delays in patients undergoing elective surgical procedures are associated with significant increases in infectious complications and mortality. Those delays also are associated with significant increases in hospital cost. The procedures looked at included elective colon resections, lung resections, and coronary artery bypasses. The association between preoperative delays and the infectious complications and mortality persisted even after adjustment for demographic factors and comorbidities. However, since the source of data was an administrative database, no information was available regarding the reason for delays, which obviously may have included other factors that predisposed to infections. Nevertheless, we know that the risk of complications of care and medical errors increases every day one is hospitalized. This study certainly suggests that hospitals should monitor and investigate cases where delays occur between admission and surgery for elective cases. It is certainly in their best interest from both a quality and patient safety perspective and a financial perspective. It should also serve as an alert to those surgeons who continue to say I like to admit my patients a day before surgery.
Lastly, a study (Alter 2011) found that patients treated with ALS (advanced life support) prior to hospitalization had higher rates of nosocomial infections than those who did not have ALS. Though this association may simply mean that patients who require ALS are sicker or otherwise more predisposed to nosocomial infections, it does highlight the need for further investigation of the prehospital environment as a potential contributory factor to nosocomial infections.
Collectively, these articles clearly show we must broaden our universe when we deal with nosocomial infections and thinking outside the box may provide us with some unexpected solutions to preventing them.
Loftus, RW, Muffly MK, Brown JR, et al. Hand Contamination of Anesthesia Providers Is an Important Risk Factor for Intraoperative Bacterial Transmission. Anesth Analg 2011; 112: 98-105
Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52
Loftus RW, Koff, MD, Burchman CC, et al. Transmission of Pathogenic Bacterial Organisms in the Anesthesia Work Area. Anesthesiology 2008; 109(3): 399-407
Koff MD, Loftus RW, Burchman CC, et al. Reduction in Intraoperative Bacterial Contamination of Peripheral Intravenous Tubing Through the Use of a Novel Device. Anesthesiology 2009; 110(5): 978-985
Roy, RC, Brull SJ, Eichorn JH. Surgical Site Infections and the Anesthesia Professionals' Microbiome: We've All Been Slimed! Now What Are We Going to Do About It?
Anesth Analg January 2011 112:4-7
Hollmann MW, Roy RC. Antisepsis in the Time of Antibiotics: Following in the Footsteps of John Snow and Joseph Lister (editorial). Anesth Analg January 2011 112:1-3
Hopf HW, Rollins MD. Reducing Perioperative Infection Is as Simple as Washing Your Hands. Anesthesiology 2009; 110(5): 959-960
Vogel TR, Dombrovskiy VY, Lowry SF. In-Hospital Delay of Elective Surgery for High Volume Procedures: The Impact on Infectious Complications. Journal of the American College of Surgeons 2010; 211(6): 784-790
Alter SM, Merlin MA. Nosocomial and community-acquired infection rates of patients treated by prehospital advanced life support compared with other admitted patients. American Journal of Emergency Medicine 2011; 29: 5764
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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