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October 1, 2013
Fuels and Oxygen in OR Fires
A new study on flammability of surgical drapes and materials raises some new points but reinforces much more strongly some old ones. Researchers assessed the flammability at various oxygen concentrations of surgical drapes, gowns, towels, and other materials commonly found near patients in the OR (Culp 2013). As expected, they found that the ignition times and total burn times decreased as the oxygen concentration increased. Some materials, such as utility drapes and surgical gowns, did not support combustion in room air. As such, they would meet Consumer Product Safety Commission (CPSC) standards. However, at 50% oxygen concentrations they would readily burn and would not meet CPSC standards for consumer wear. They did find some difference in flammability of materials based on characteristics of the material. For example, laparotomy sponges, which are woven, burned more readily than blue operating room towels even though both are made of 100% cotton. They speculate that the open weave of the laparotomy sponge allows for more exposure to oxygen. However, they also noted that flash fires (rapidly moving flames that appear to be almost instantaneous and may or may not lead to a base material burn) were seen on the blue operating room towels and laparotomy sponges in oxygen-enriched environments.
They note that such flash fires occur so rapidly that operating room personnel could not possibly respond effectively. Hence, efforts at fire prevention are crucial.
And while the authors recommend that further research should be undertaken to identify materials that are less flammable, they restress the importance of supplemental oxygen in surgical fires. That is also the gist of the accompanying editorial (Eichhorn 2013). Eichhorn points out that many anesthesiologists fail to recognize the great risks caused by open supplemental oxygen (nasal cannulae or perforated facial masks used with 2 or 3L/min oxygen flow) during monitored anesthesia care (MAC). That is certainly supported by the malpractice claims study we highlighted in our June 25, 2013 Patient Safety Tip of the Week “Update on Surgical Fires”. In that study (Mehta 2013) 99% of cases involved procedures known to be high risk for fires (head, neck, or upper chest surgery), electrocautery was the ignition source in 90%, and oxygen was the oxidizer in 95%. The vast majority of claims were for fires that occurred during monitored anesthesia care rather than general anesthesia and in the vast majority of claims involving monitored anesthesia care the oxygen was delivered by an open delivery system. There has been a trend for surgical/OR fires to be seen more often in relatively minor surgery (eg. plastic procedures, removal of skin lesions, temporal artery biopsies, etc.), done under sedation or monitored anesthesia care where there is open delivery of oxygen.
Eichhorn notes that eliminating open delivery of supplemental oxygen during upper body MAC procedures has been a focus of the Anesthesia Patient Safety Foundation. He notes that supplemental oxygen is overused and in many cases is unnecessary. Though he does discuss some less reliable strategies to mitigate the oxygen risk, he stresses that the patient who truly needs oxygen should receive it via a laryngeal mask or endotracheal tube. The recently updated ASA Practice Advisory for the Prevention and Management of Operating Room Fires (Apfelbaum 2013) also stresses that.
Eichhorn also notes that residual alcohol-based prep solutions will also burn faster and more intensely in higher oxygen concentrations. We discussed the role of alcohol-based skin preps or other volatile substances in our April 24, 2012 Patient Safety Tip of the Week “Fire Hazard of Skin Preps, Oxygen” and our June 25, 2013 Patient Safety Tip of the Week “Update on Surgical Fires”.
After a patient suffered burns to the neck and shoulders from a fire during an emergency surgical procedure, one hospital (Natt 2013) recently implemented a policy prohibiting alcohol-based skin preps in any emergency surgery that does not allow sufficient drying time (usually 3 minutes or longer). Instead they have gone back to non-alcohol-based preps like Betadine for such emergency cases.
While we still recommend every organization perform drills on how to respond to OR fires, we concur with Culp and colleagues and Eichhorn that the focus needs to be on prevention. We’ve emphasized in the numerous columns below the need to include a fire risk assessment in your pre-procedure “huddle” and include this in your Surgical Safety Checklist. Eichhorn points out that our training in anesthesiology residency programs (and inservicing and continuing medical education for previously trained anesthesiologists) must focus on the need to avoid open delivery of oxygen in procedures done under MAC.
Our prior columns on surgical fires:
Patient Safety Tips of the Week:
What’s New in the Patient Safety World columns:
Culp WC, Kimbrough BA, Luna S. Flammability of Surgical Drapes and Materials in Varying Concentrations of Oxygen. Anesthesiology 2013; 119(4): 770-776
Eichhorn JH. A Burning Issue: Preventing Patient Fires in the Operating Room. Anesthesiology 2013; 119(4): 749-751
Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating Room Fires: A Closed Claims Analysis. Anesthesiology 2013; 118(5): 1133-1139, May 2013
Apfelbaum JL, Caplan RA, Barker SJ, et al. Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013; 118(2): 271-290
Natt TM. Operating-Room Fire at Hospital Burns Patient, Prompts Changes. thepilot.com August 9, 2013
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October 8, 2013
EMR Problems in the ED
We’ve often noted that 2 key areas of the hospital are often poorly integrated with the electronic medical record of most hospitals: the ER and the OR. In many hospitals, electronic medical records were first adopted on inpatient units and only later are emergency departments brought on board, often with modules that do not fit well with the workflow of the emergency department. In other cases, emergency departments have adopted their own electronic medical record programs specifically designed for the ED but not integrating well with the hospital-wide EMR.
Recently there have been several articles in the emergency medicine literature highlighting many of the problems resulting from these issues. In the first, Hill and colleagues (Hill 2013) looked at the impact of their emergency department electronic medical record on physician workflow. They found that emergency physicians at their hospital spend 44% of their time, on average, entering data into the EMR and only 28% of their time on direct patient care (remaining time was 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities). They estimate that during a typical 10-hour shift an emergency physician averages 4000 mouse clicks!
In another significant article (Farley 2013) members of the Quality Improvement and Patient Safety Section and Informatics Section of the American College of Emergency Physicians came together to focus on potential benefits and threats seen with emergency department information systems. They identified multiple areas of patient safety concern, including communication failures, wrong-patient/wrong-order entry, poor data display, and alert fatigue.
Communication failures are common relating to information systems in the emergency department. Examples given include instances where a verbal order may be given and then the order is duplicated when the physician gets around to inputting the orders in the CPOE system, resulting in the patient receiving a double dose of medication or duplication of a lab test. Also, unfortunately, the EMR often becomes the primary means of communication between healthcare professionals about a patient and often detracts from having face-to-face interactions. EMR’s often use templates or providers do cut-and-paste notes and the subsequent notes often make it difficult to summarize the patient’s course.
Poor data display and scrolling issues are common. They provide examples of how critical values may not be flagged in a manner to catch the attention of the emergency physician and cases where a physician might quickly click an “accept all” button and miss an important result.
And, of course, alert fatigue is an issue with EMR’s in all settings, the emergency department included.
Their other major issue was wrong-patient/wrong-orders. They provided examples of how a busy ED physician, caring for multiple patients simultaneously, can easily be distracted during CPOE and come back and enter orders into the EMR of another patient. As far back as 2008 we speculated that wrong patient errors would be more frequent with electronic medical records than paper medical records (see our May 20, 2008 Patient Safety Tip of the Week “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”). In that column we discussed multiple factors that make such errors more likely. One of the key potential solutions is to ensure that appropriate patient identifiers appear on every screen. Our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE” highlighted some other interventions designed to reduce such wrong patient errors. Authors of one study (Adelman 2012) piloted two distinct interventions, an “ID-verify alert” and an “ID-reentry function” that reduced the occurrence of such errors.
One of the interventions we have long recommended is inclusion of patient photographs in the EMR. Several organizations have successfully used photographs to reduce wrong-patient/wrong-order incidents (see our June 26, 2012 Patient Safety Tip of the Week “Using Patient Photos to Reduce CPOE Errors”). But there may be limitations to patient photographs that impact the emergency department more so than the rest of the hospital. A major one is that often the patient coming to the ED may not look anything like a pre-existing photograph in the EMR (eg. a trauma patient). Also, a patient presenting to the ED may be new to the system and have no pre-existing photograph in the EMR. Therefore, each facility would need to have a policy and procedure in place for rapid capture and posting of the photographs upon the patient’s arrival in the ED.
But one other problem we’ve noted before continues to persist – the fact that a provider may have several applications open simultaneously and they may not be synchronized to show the same patient. For example, and ED physician might have the EMR of a patient open and also have open the PACS system or lab system where he is looking at results on multiple patients. In that scenario it is very easy to return to the EMR thinking you are looking at a different patient. The ideal system to synchronize patients in diverse IT applications is lacking to date.
Authors in the Farley article developed 7 important recommendations for improving problems with emergency department information systems. First is that a local ED physician “champion” should be appointed to lead the performance improvement activities for the emergency department information systems. Second, that a multidisciplinary IS performance improvement group meet regularly and communicate regularly with the ED leadership and hospital leadership. Third, there should be a regular process to review safety issues related to the emergency department information systems and that prospective risk assessments be done. Fourth, when patient safety issues related to the emergency department information systems are identified, they must be addressed promptly and in a transparent manner with the ED personnel, hospital administration, and IT vendors. Related to the latter is a recommendation that lessons learned be shared publicly and with other ED’s using the same information systems. Specifically, they call for elimination of the “gag” clauses common to many vendor agreements that preclude hospitals or hospital personnel from disseminating information about such issues and errors. They also recommend that changes to information systems in response to patient safety issues be done in a timely fashion and distributed to all installation sites. And, lastly, they recommend that “hold harmless” clauses (in which IT vendors are absolved of all liability) be removed from contracts.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
Hill RG, Sears LM, Melanson SW. 4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED. The American Journal of Emergency Medicine 2013; In Press, Corrected Proof, Available online 21 September 2013
Farley HL, Baumlin KM, Hamedani AG, et al. Quality and Safety Implications of Emergency Department Information Systems. Ann Emerg Med. 2013; xx: xxx
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc 2012; Published online 29 June 2012
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October 15, 2013
There’s been considerable interest in how to deal with missing patients in view of the recent news of a missing patient found dead at San Francisco General Hospital (Ho 2013). For those of you not familiar with that case, a 57 y.o. female inpatient on a med-surg unit went missing from the hospital on September 29 and she was found dead in a stairwell at the same facility 17 days later. Findings of both the internal root cause analysis and the external investigation are not yet known. Nevertheless, this incident at a hospital known for its high level of commitment to patient safety should make everyone say “could that happen here?”.
When that news broke we went back and reviewed our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients”. We think the advice and recommendations in that column remain so relevant that we’ve decided to print it again in its entirety below.
There are a couple other useful resources pertaining to missing patients that have become available since our earlier column. One is a directive in the VA system regarding management of wandering and missing patients (VHA 2010). The VHA directive includes recommendations about assessing all patients for risk of wandering or becoming missing while in treatment. It then describes what should be done when a patient is found to be missing, including both preliminary and full searches. It discusses designation of persons to be responsible for various aspects of the response to a missing patient, including “off-hours” as well as during usual business hours. Particularly useful is the discussion of the full search. This includes superimposing a grid map over a site and facility plot to delineate the search sectors. One individual is assigned responsibility to ensure all search grid sector assignments are made, the times and by whom grid sectors are searched, times and by whom each building is searched, times and to whom notifications and requests are made, and results of the searches. The recommendations include a description of both the indoor search and the outdoor search. It describes that each search team has a leader and how members of the search teams are to conduct their searches.
Obviously, all staff must have a thorough understanding of what to do during a search. This can be done through orientation, competency assessments, and regular drills.
One particularly good piece of advice from the VHA directive is to ensure that someone from the hospital is assigned the responsibility of regular contact and followup with the missing patient’s family and friends.
Another good piece of advice comes from the Minnesota Hospital Association (MHA 2011). Most of you are aware of the movement to replace “codes” with plain language for paging emergencies in hospitals (and other healthcare settings). In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we noted your “code” should be announced with a brief description of the missing patient (age, sex, race, unit, etc.). The MHA recommends that the plain language overhead page be: “Missing person (of any age) + descriptor (and as appropriate, action for staff/patient/visitors.)” We think that including something about the action to take is important for both staff and visitors.
Also, you may want to note that we’ve done several columns pointing out the role of smoking in patient elopements (see our December 2012 What’s New in the Patient Safety World column “Just Went to Have a Smoke” and our April 2, 2013 Patient Safety Tip of the Week “Absconding from Behavioral Health Services”).
One other point not included in either our prior column nor the VHA directive is that all surveillance cameras should be accessed to see if the missing patient can be seen. This would include not only any internal security cameras at your facility but also any external security cameras (parking lots, etc.). You might also consider security cameras that might be available at neighboring stores, service stations, etc.
Update: Please also see our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”.
Here is our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients”:
July 28, 2009 Wandering, Elopements, and Missing Patients
The May 25, 2009 issue of Inside the Joint Commission Online has several articles dealing with wandering, elopements and missing patients. The issue was apparently triggered by an unfortunate sentinel event in Pittsburgh in which an elderly woman with dementia wandered onto a roof and froze to death. All types of facilities need to develop policies and procedures for:
1) doing an assessment for risk of wandering or elopement
2) implementing risk reduction strategies for those patients at risk
3) performing a prompt and thorough search when a patient is missing
Many of the risk factors for wandering and elopement are also risk factors for delirium. So if you have been following this column and begun screening for delirium risk factors, you are halfway there! Alzheimer’s disease or any dementia may predispose the patient to wandering. Most of you recognize the term “sundowning” which we apply to those patients with dementia who become more confused and disoriented in new unfamiliar settings such as the hospital. Such patients may be prone to wandering and elopement. But any patient with impaired cognition may be at risk. This includes patients with psychiatric disorders, developmental disabilities, and acquired neurological disorders. But there are other risk factors or contributing factors as well. Many of the drugs we’ve talked about under delirium (particularly sedating agents) may contribute. A prior history of wandering or elopement (eg. at a long-term care facility prior to admission) should be a red flag.
Some standardized questions that appear on most wandering assessment tools are:
Others have emphasize “exit-seeking behavior” such as talking about going home or asking about things not available on the unit (typically something such as candy bars).
Just as with fall risk assessments or delirium risk assessments or even DVT risk assessments, things change during a hospitalization. Therefore, a single assessment for elopement risk on admission is not sufficient. That risk assessment must be repeated after surgery, at internal transfers of care, and any time there has been a significant change in the patient’s mental status or overall medical status. The same patients should have formal risk assessments for delirium and falls.
So what do you do when you identify a patient as being at-risk for wandering or elopement? It makes sense to put them in a room where staff would be more likely to see them exit the room (usually closer to the nurse’s station). Many floors have one or two rooms that are video monitored, a logical choice for such patients. Consider having the patient wear a gown that is a different color than the usual gowns so that all staff would recognize such patient as being “lost” if encountered in other parts of the hospital. Potential exit doors on the unit should be fitted with appropriate alarms (that are functioning correctly) and with appropriate signage to keep the door closed. Consider keeping the patient in a room with a roommate or have family members stay in the room. Attention to the patient’s physical needs (food, water, warmth, pain management, toileting) are important. Letting the patient walk or exercise under supervision may be useful. The references below (AHRQ Web M&M, Veteran’s Administration Wandering Resources, Spencer 2008, Evidence-based guideline: Wandering) all contain excellent points on care management of the patient at risk for wandering.
Internal patient transports may also be vulnerable events. You’ve heard us talk on several occasions about the “Ticket to Ride” concept in which a formal checklist is completed for all transports (eg. to radiology). Such checklists typically contain information related to adequacy of any oxygen supplies and medications needed but should also include information about things like suicide risk and elopement risk. These all need to be conveyed to the caregiver who may be accepting the patient in the new area. Just as we’ve talked about cases where a patient may attempt suicide in a bathroom in the radiology suite that is not suicide-proofed, a patient at risk for elopement may wander off easily while waiting in the radiology suite if not appropriately supervised.
The response to a missing patient is critical. It must be rapid, well-planned, and thorough in order to find the patient before he/she suffers any harm. Some facilities have chosen to merge their infant abduction policy with the elopement or missing patient policy since the procedures may be very similar. But be careful – you don’t want your staff searching for a newborn by mistake when they should be looking for a wandering geriatric patient.
Staff on the unit need to be notified as soon as a patient is missing. A very brief head count of patients and look in rooms on a unit is typically done but this should last no more than a couple minutes. At that point the hospital phone operator should be notified and “code yellow” (or whatever name you use at your facility) should be announced over the public address system. It should be announced with a brief description of the missing patient (age, sex, race, unit, etc.). Exits from the building need to be immediately locked (some doors may be locked from a central location) or manned by designated staff members. No one should be allowed to leave the building(s). The operator may notify visitors over the PA system that they are under no danger but need to avoid going near exits for the time being. Key assigned staff should immediately go to a designated “command center” from which they will direct the response. Each unit (clinical and nonclinical) will have a specific predetermined area they must search in a systematic fashion. The command center must have an overlay grid of the buildings and surrounding areas and be able to mark off areas on the grid that have been searched. The search teams must have keys to their search areas since sometimes patients lock themselves into rooms inadvertently.
We also recommend early outdoor search since a patient can easily stray far from the building (or into automobile traffic) in a very short period of time. We also recommend that the local police department be notified immediately by the operator when the “code yellow” is called (don’t forget to include them in your planning process). Many facilities also use many security video cameras that are monitored centrally. Security staff may be able to scan those quickly to look for a patient exiting the building.
Someone on the unit from which the patient disappeared should be designated to send out a general email to all saff, describing the missing patient and including a photograph if one is present on the information system. The patient’s physician should be notified by the operator or staff on the patient unit. Someone needs to be designated to be in communication with the family as well.
What do you do when you find the patient? First, be aware they are likely confused and be careful not to frighten them. Do a brief assessment as to whether they may have been injured. Notify the command center you have found the patient and either return them to their unit or to the emergency department. They should be evaluated by a physician at that time to determine whether any injuries have occurred. In the unfortunate circumstance where the patient is found dead, the scene should be left undisturbed because the authorities will treat it as a crime scene.
Drills are critical for any event that is likely to be rare but critical when it occurs. Just as we’ve hammered home in our discussions about surgical fires, it is important that all staff know what to do during certain emergencies and the best way to prepare for those is with drills. Yes, you can and should include education and training on missing patient alerts during orientation and annual reorientation but you have to periodically run a drill to see whether the responses are adequate and timely. During drills one may also see various nooks and crannies and other areas (eg. ventilation ducts) that a patient could get into, perhaps leading to some physical improvements to prevent such dangerous access. You might also consider using a “secret wanderer” (person dressed as a patient in one of the special colored gowns) to see if staff identify them as a wanderer.
Staff education obviously is important but should be ongoing rather than just being delivered at annual orientation sessions. The Bay Pines (Florida) VA Hospital uses a creative reminder device on patient care areas that is shaped like a stop sign and uses the mnemonic “DON’T GET LOST” which stands for:
D Determine at-risk patients
O Observe for wandering triggers
N No-fall environment
T Teach staff/nonclinical support
G Get patient involved in activities
E Exit control
T Talk to patient and provide reassurance
L Low patient to staff ration
O Offer food, drink and toileting
S Structure and routine
Ongoing surveillance is also important. When we do patient safety walkrounds we also incorporate much of what traditionally has been termed environment of care rounds. We look to see that doors and other accesses to dangerous places are locked and appropriately alarmed. We also look at windows leading to rooftops and make sure no one could open them and exit onto a rooftop.
How can technology be utilized to minimize the risk of elopement? There are several technology devices that can be used to alert staff when at-risk patients are leaving their bed or their area of care and others that can be used to track and locate such patients. All agree that such systems should never be relied on as the sole means of monitoring such patients. And each day the system/device should be checked to ensure it is functioning properly.
In addition, our electronic medical records (EMR’s) and clinical decision support tools can be used to help identify at-risk patients and flag them as being at-risk. For instance, if a patient has wandering during one hospitalization (or wandering during a LTC stay), his medical record can have a flag set that identifies him as at risk for wandering during future admissions.
You probably will be unable to prevent every potential elopement. When one does occur, do a debriefing session as soon as possible to identify potential missed clues and other useful lessons. Then do a formal root cause analysis within a short timeframe. There are always valuable lessons learned that hopefully can prevent other elopements in the future.
Elopement. Inside the Joint Commission Online 2009; 15:4-8. May 25, 2009.
Gerardi D. AHRQ Web M&M Case. Elopement. December 2007
Veterans’Administration. Wandering Resources.
National Guideline Clearinghouse. Evidence-Based Guideline: Wandering.
Spencer E. Policy for Assessment and Care Management of Patients who are at risk of Wandering in the Acute Care Setting. University Hospitals of Leicester. August 2008
Ho V. Body in SF General stairwell IDd as missing patient. San Francisco Chronicle 2013; SFGate.com Updated 10:46 pm, Wednesday, October 9, 2013
Department of Veterans Affairs. Veterans Health Administration (VHA). VHA Directive 2010-052. MANAGEMENT OF WANDERING AND MISSING PATIENTS. VHA 2010; December 3, 2010
Minnesota Hospital Association (MHA). Plain Language Overhead Emergency Paging. Implementation Toolkit. 2011
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October 22, 2013
How Safe Is Your Radiology Suite?
So just how safe is your Radiology suite? We’re not just talking about the risk of radiation to your patients (though we will do a brief update on that at the end of today’s column) or the risks of the radiological procedures themselves. And we are not talking about diagnostic errors in interpreting imaging studies or failure to adequately convey critical test results to the appropriate physician. We’re talking about all the other potentially bad things that can happen to your patients while they are in the Radiology suite. Things like falls, medication errors, patient mixups, IV connection errors, running out of oxygen, conscious sedation incidents, suicides, and others.
Many of our columns have highlighted the radiology suite as a site where many patient safety issues occur (see our Patient Safety Tips of the Week for October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”, September 16, 2008 “More on Radiology as a High Risk Area”, and October 7, 2008 “Lessons from Falls....from Rehab Medicine” and our January 2010 What’s New in the Patient Safety World column “January 2010 Falls in the Radiology Suite”). In several of these we noted that radiology is an area where falls often happen. Patients are often on a gurney or a table or in a wheelchair and may fall when they attempt to get up to use the bathroom. They may be tethered to IV poles or other equipment that become obstacles to trip over. And they may have received benzodiazepines or other sedating medications for the radiology procedure, further increasing their fall risk. So it is critical that the fall risk of a patient is accurately conveyed to all staff when a patient is sent to radiology. One way to facilitate such handoffs would be to include information on fall risk in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column “Oxygen as a Medication”. The use of color-coded wristbands continues to gain momentum and may be used to identify patients at greater risk for falls.
Most of the literature has focused on inpatients in the radiology suite. In one study of falls in a radiology department (Abujudeh 2011) 80% of falls occurred in outpatients. However, that reflected the relative proportion of radiological examinations done on outpatients compared to inpatients. 44% of the falls were related to the procedure being performed (eg. patient fall from an examination table). A majority (72%) occurred while the patient was standing or ambulating and most (61%) were unassisted falls. 85% had at least one known risk factor predisposing to falls. Those who fell were more likely to be older, have altered mental status, have a history of falls, and be taking antihypertensives or CNS-acting medications. Though the overall rate of falls was low (0.46 per 10,000 imaging examinations), almost a third (29%) of the falls resulted in injury. The likelihood of sustaining an injury related to the fall was statistically significantly associated with ambulating at the time of the fall and being on CNS-acting medications.
They recommend consideration of several aspects to develop a fall reduction program in a radiology department. These include adherence to assistance by staff, avoidance of walking in socks, careful observation of surroundings, slow and steady mobilization, use of eyeglasses, and use of extreme caution if using certain medications.
Though they didn’t go into details, 5% of the falls in their study occurred in visitors. Since we can’t do the risk assessments on visitors, that suggests we need to pay more attention to environmental factors such as clutter, rug edges, etc. (see below).
The Pennsylvania Patient Safety Authority reviewed its reports of serious events involving falls from 2005 to 2009 and found that falls accounted for 8% of reports from Radiology departments (PPSA 2011a). They note that the interventions put in place on inpatient units to prevent falls may not be replicated in patients transported to Radiology.
They found four themes that occurred in over half the reports of falls in Radiology: syncope, slips/trips/loss of balance, falls from stretchers or tables or stools, and medication-related events.
Cases involving syncope or near-syncope accounted for 17% of reports. One factor implicated in some falls in Radiology is fasting. They may have been fasting in preparation for a procedure. In addition, other preparations for some procedures (eg. barium enema) may lead to hypovolemia, predisposing patients to orthostatic hypotension. Remember, some of the studies being done in Radiology require the patient to stand still in the upright position, promoting orthostatic hypotension in vulnerable patients. Others go from a supine position on a table or cart to the upright position for transfer, similarly promoting orthostatic hypotension. And many patients are on medications that have orthostatic hypotension as a side effect.
15% of their Radiology falls involved slips, trips or loss of balance. They note both use of walking aids (eg. canes, walkers) and failure to use walking aids contributed to falls. They note that patients are often left unattended in some areas of Radiology prone to falls, such as bathrooms, dressing rooms, and waiting areas. They also noted that patients’ clothing or footwear might become entangled with a variety of equipment and other obstacles in Radiology.
Stretchers and tables are also commonly implicated (12% of reports). Patients may fall from transport vehicles or from tables and chairs being utilized for imaging studies. They note that sometimes patients on gurneys or stretchers with siderails will crawl down to the end of the gurney, resulting in tipping the gurney over and falling.
Medications, particularly those likely to impair mentation (eg. opiates and benzodiazepines), were also commonly implicated in falls in Radiology. Sometimes the medication was even given in Radiology (eg. sedation given for claustrophobia before an MRI).
The PPSA study notes that Radiology staff often do not participate in the falls risk training that inpatient staff participate in. So they recommend educational and inservice interventions for all Radiology staff to promote awareness of fall risk and measures to reduce that risk. Transport personnel should be included in such training. Formal fall risk assessments should be done on patients in Radiology. Whereas many inpatients have had a fall risk assessment prior to going to Radiology, those coming from the emergency department typically have not yet had a formal fall risk assessment. Nor do most outpatients coming to Radiology for imaging studies have fall risk assessments. The Pennsylvania Patient Safety Authority has an excellent radiology falls risk assessment tool (PPSA 2011b). They also note the importance of involving patients and family in increasing awareness of fall risk. Displaying a poster (eg. “Are you at risk for falling?”) in the waiting area is one recommendation. We’ve previously noted the importance of communicating fall risk in handoffs, particularly on the “Ticket to Ride” tool often used for patients transported to Radiology. The PPSA echoes that strategy. Remember also that patient transport is bidirectional. After a patient has finished in Radiology there should be appropriate communication back to the destination unit.
Environmental conditions obviously must be dealt with to minimize falls. Many corridors in Radiology suites become cluttered with equipment, transport vehicles, chairs, etc. Careful attention must be paid to floor surfaces, rugs, and steps that may lead to patients tripping and falling. Also floors may become slippery due to fluid leaks from IV’s, incontinent patients, moisture brought in from outside on boots and shoes, and other sources. We always look for such conditions when we do Patient Safety Walk Rounds. But such walk rounds should become a daily exercise for staff in the Radiology suite itself. Just as with falls on inpatient units, many falls in Radiology occur in relation to patients using bathrooms so special attention must be paid to them on such rounds. But just as important is ensuring that there is staff available to help patients in Radiology use the bathroom when necessary. Ensuring adequate lighting is also essential.
One frequently overlooked risk factor is footwear. While we usually supply non-slip footwear for inpatients whom we identify as being at high risk for falls, outpatients or ER patients are more likely to be in socks or stockings that might promote falls.
Our October 16, 2007 Patient Safety Tip of the Week “Radiology as a Site at High-Risk for Medication Errors” highlighted a United States Pharmacopeia (USP) MEDMARX® Data Report “A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services” (USP 2006). Though the overall number of medication errors in radiology areas was small, USP pointed out that the percentage of cases resulting in patient harm was considerably higher than seen with medication errors elsewhere. 12% of the medication errors in these areas were considered harmful to patients, about 7 times higher than the percentage in the overall MEDMARX® database. Using the Pareto principle, almost 80% of the errors fell into 4 types of error: improper dose/quantity, unauthorized/wrong drug, omission error, and wrong administration technique.
Many of the errors were attributable to problems outside the radiology department or had root causes outside the radiology department. This draws attention to a whole host of system issues that interplay to result in errors that happen to manifest themselves while a patient is in the radiology suite. Our July 31, 2007 Tip of the Week “Dangers of Neuromuscular Blocking Agents” gave an example of an incident where an emergency room resident inadvertently administered a neuromuscular blocking agent to a patient he had accompanied to the radiology suite for a CT scan. Obviously, that had little to do with “radiology” per se but does draw attention to potential high risk situations.
Below are some of the issues, conditions, and circumstances pertaining to radiology areas that may predispose patients to suffer medication (or other) errors:
Medication reconciliation and communication issues are two of the most important issues giving rise to medication errors in any setting, and from the above you can see that the radiology suite is no different. An article in the April 2006 American College of Physicians Observer, “Imaging hand-offs: Tips to help prevent medication errors” (Darves 2006) describes what the internist (or any physician with primary patient responsibility) can do to reduce the likelihood of medication errors relating to the radiology suite. In particular, that article addresses some of the issues related to interactions between certain medications and contrast agents (either directly or indirectly through effects on renal function). The importance of communication and defining roles (eg. who is responsible for followup actions) is stressed.
There are, of course, issues specific to radiology as well. These often pertain to use of contrast agents. This is especially likely to occur when there is inadequate information about previous allergies or renal function. There have also been numerous cases where the wrong type or wrong dosage of a contrast agent has been injected during myelography with disastrous results, often because of inadequate labeling or storage. And the issue of unlabeled syringes or basins is as big an issue in radiology as it is in the OR. Many remember an unfortunate case a few years ago where a patient was inadvertently given the antiseptic skin prep solution, chlorhexidine, instead of contrast media intraarterially (ISMP 2004).
The second major study on medication errors in Radiology comes from the Pennsylvania Patient Safety Authority (PPSA 2009). They reviewed almost 1000 reports of medication errors from Radiology services over a 5-year period. Errors related to contrast agents or other agents used for imaging studies accounted for only about a quarter of the events. Rather, the vast majority of medication errors were related to drugs that are used throughout the hospital. Moreover, many of the leading drugs involved were high-alert medications, like insulin, opioids, and anticoagulants. Some involved moderate sedation being used for the imaging procedure. The most common error types were wrong drug, dose omission, wrong dose or overdose, and wrong rate. Drug omissions were particularly problematic. They cite examples of infusions of insulin or heparin that were stopped for prolonged periods while the patient was in Radiology leading to untoward consequences. Almost 11% of reports involved problems with infusion pumps or IV lines. They also noted errors related to patient information, with lack of concurrent information about medications, lab values, patient weights, etc.
PPSA suggested several strategies to reduce the risk of medication errors in Radiology including:
Because of the frequency of medication errors in Radiology and fact that the errors often involve high-alert medications and seriously ill patients, this is probably the patient safety consideration in Radiology that merits the most attention.
Wrong Patient, Wrong Site, Wrong Test, etc.
As we’ve often mentioned, over 50% of “wrong-site, wrong-patient, wrong-procedure” events occur outside the OR. In our December 6, 2010 Patient Safety Tip of the Week “More Tips to Prevent Wrong-Site Surgery” we noted a study (Stahel 2010) highlighting the continued occurrence of wrong-patient and wrong-site occurrences. Such occurrences also happened in Radiology or Radiation Oncology settings. That study highlights the importance of the “time-out” in multiple venues of patient care where correct identification of patients and clinical information is critical.
The Pennsylvania Patient Safety Authority (PPSA 2011c) found in its database 652 events in 2009 of wrong procedure or test (50%), wrong patient (30%), wrong side (15%), and wrong site (5%) events occurring in Radiology settings.
Incorrect orders or requisition entries were one of several root causes identified. As we’ve noted previously in our many columns on wrong-site events, information coming from physicians’ offices may contribute to the problem. Given the volume of imaging studies ordered, this may be even more problematic for radiology than for surgery. Unfortunately, one problem we continue to see is that the orders or requisitions for imaging studies are often filled out by someone other than the physician (often a nonclinical person) and inaccurate information appears on the requisitions. This especially applies regarding the question about use of contrast. Other errors might include the type of study. The PPSA study noted that for mammography there were considerable errors in ordering screening vs. diagnostic mammograms. Also, since some imaging studies get ordered on paper requisitions (or simply on prescription forms) illegible handwriting remains a problem.
Failure to confirm patient identity is another major root cause. To comply with Joint Commission standards all facilities must use at least 2 forms of identification for all procedures, including imaging studies. Moreover, such identification must be active rather than passive. It is not acceptable to even ask a patient “Are you Mary Jones?”. You must ask the patient to say their full name. Most facilities use the date of birth as the second form of identification so the patient should be asked to say their date of birth aloud. The PPSA study had numerous examples of the wrong patient responding to a call in the waiting room and subsequently getting the wrong study. There were also examples of transport services bringing the wrong patient but the correct chart to the Radiology suite. Especially problematic are cases where the room of a patient has changed and someone wrongly assumes they have the original patient (remember, Joint Commission does not allow room number or location to be an identifying item). Also, don’t forget that it is common to have names that sound alike or even names that are identical.
Failure to follow site and procedure verification or procedure qualification processes was the other major root cause in the PPSA study. One error we’ve previously mentioned for wrong-site procedures is actually being misled by the patient. The PPSA study had examples of a radiology technologist listening to the patient’s symptoms and thinking the exam was for a specific body part when, in fact, the physician was interested in an exam of a totally different body part. But this category also included inadequate screening (for instance failure to screen for implants, etc. before an MRI, failure to screen for pregnancy, failure to look for renal dysfunction prior to use of contrast, etc.).
PPSA notes that failed communication really contributes to all three of the above root causes and notes the need for programs that improve communication, team work and safety culture. But they also note the importance of using the Joint Commission Universal Protocol for imaging procedures and actually provide a nice Radiology Services Patient and Procedure Identification Assessment tool (PPSA 2011d) to help. The paper also provides multiple other strategies you should consider.
We’d also like to mention that use of patient photographs may have a valuable role, not only in avoiding wrong patient issues but also in improving radiologists’ interpretation of images. See our April 30, 2013 Patient Safety Tip of the Week “Photographic Identification to Prevent Errors” for examples of use of patient photographs to identify wrong-patient cases in radiology.
Later in today’s column we also mention two tools that are modifications of the WHO Surgical Safety Checklist, modified for interventional radiological procedures. The WHO Surgical Safety Checklist: for Radiological Interventions ONLY checklist is downloadable here. A second safety checklist for interventional radiological procedures, modeled after the WHO Surgical Safety Checklist, appears in a recent article by Canadian radiologists (Athreya 2013).
Moderate sedation (also formerly known as conscious sedation) is utilized in many procedures performed in the Radiology suite or MRI suite. The physicians must be credentialed to do moderate sedation and the nursing staff have up-to-date competencies in moderate sedation. Appropriate equipment for resuscitation needs to be immediately available. Identification of patients at high risk (eg. those with COPD or sleep apnea or certain neuromuscular disorders) is important and an anesthesiologist’s presence might be required for such patients. Monitoring of patients is crucial, particularly since different patients react differently to the same doses of various agents used in sedation. In addition to monitoring vital signs, level of consciousness, and pulse oximetry, there has been an increasing trend to also use capnography for monitoring.
But in addition to the procedure and moderate sedation itself, keep in mind that these patients may be at increased risk for falls for some time after the procedure.
Problems with oxygenation
Some seriously ill patients need imaging studies and many of these can only be done in the Radiology suite. Hence it’s not uncommon to have patients on oxygen or even on mechanical ventilation in the Radiology suite. Unexpected extubations may occur in Radiology. We’ve also mentioned previously that “Ticket to Ride” handoff tools arose primarily because previous studies showed that half of ICU patients transported to Radiology ran out of oxygen at some point.
The old literature also cites instances where wall-mounted gas lines were transposed. However, we expect that all facilities have addressed the issue and taken steps to prevent inadvertent misconnection to wall-mounted gas sockets.
We discussed many errors related to IV lines in the section above on medication errors. These include things like stopping IV infusions for a procedure and forgetting to restart them, misprogramming of infusion pumps, patients getting the wrong drugs, etc.
But the PPSA study on medication errors in Radiology also notes tubing misconnection errors. They describe one case where contrast and saline were injected into a tracheostomy cuff rather than an IV line (the connectors apparently looked similar).
Suicides in the Radiology Suite
We have previously done several columns on preventing suicides in hospitals:
We encourage you to read those columns since they have many practical considerations. You need to be especially cognizant of the risks when patients go elsewhere in your facility. An AHRQ WebM&M Case & Commentary several years ago noted a suicide attempt occurred in a bathroom in the radiology suite. We wonder how many hospitals would have inspected that bathroom for potential suicide risk. We’ve done that in several hospitals and uniformly found that not only do those bathrooms have numerous “loopable” items that could be used for hanging but also that they can be locked from the inside and there is typically no one readily available with a key to get in. In fact, that is one of the items we added to our patient safety scavenger hunt list (see our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”). Bathrooms on non-psychiatric floors may be especially problem prone. Not only are they seldom assessed for tools and implements that could be used for suicide, but some also allow the door to be locked from the inside. So observation protocols for potentially suicidal patients on such units should ensure that doors are not locked (or, if they can be locked, that the “observer” has keys to access the bathroom). Having observers of the same gender as the patient also is recommended.
Communication of suicide risk to all parties is particularly important during transports within the hospital (such as going to the radiology suite). Your “Ticket to Ride” handoff tool for hospital transports should also be used to properly prepare for potentially suicidal patients.
Some patients may come to Radiology with a known suicide risk. But sometimes patients may present first to Radiology for a procedure and staff there may identify the patient as being at risk for suicide. Radiology staff therefore need to be aware of identifying patients at risk for suicide and know what interventions to take. A recent article (Penzias 2013) and a related story board are good resources to review on this issue.
Some procedures done in the Radiology suite (invasive procedures, insertion of catheters, etc.) must be done under sterile conditions and require good technique and adherence to good practices such as, for example, use of the central line insertion checklist.
But the Radiology suite is visited regularly by patients with all sorts of infectious illnesses, many with multidrug-resistant organisms. In addition, we are seeing more and more MRSA and C. diff infections in the community so outpatients with these infections are also visiting the Radiology suite.
So not only is strict adherence to hand hygiene guidelines important but you need to be working with your infection control personnel to ensure that other appropriate precautions are taken and that equipment, examination tables, etc. get appropriate disinfection.
One special consideration for Radiology departments is the issue of potential exposure of a fetus to ionizing radiation. As such Radiology services always inquire about the possibility of pregnancy before doing tests that utilize ionizing radiation unless the situation is a life-and-death emergency.
Nevertheless, the issue is a very complex one. The potential benefits of the procedure must be balanced against the potential risks in all cases. Also, the potential use of alternative imaging modalities that do not use ionizing radiation (eg. ultrasound, MRI) instead must be considered in each case.
Unfortunately, there is no hard and fast standard today about how to screen for possible pregnancy. While almost all facilities ask females of child-bearing age about the possibility of pregnancy and/or timing of their last menstrual period, we’ve all seen cases where that information did not correctly identify a pregnancy. In fact, no method of screening is likely to be 100% predictive.
The American College of Radiology and the Society for Pediatric Radiology have recently revised their guideline regarding use of ionizing radiation in pregnant or potentially pregnant women and adolescents (ACR 2013). We encourage you to read it since the issues are too complicated to be summarized here. There are some imaging studies that run a very low risk of potential harm to the fetus and might be done even if pregnancy is known and the woman is likely to benefit from the study. Others, that are likely to expose a fetus to higher doses of ionizing raditiation (eg. fluoroscopy of the pelvis, CT scan of the abdomen/pelvis, etc.), would require closer examination of the potential risks and benefits. Many facilities might require a formal pregnancy test before doing those studies in a woman who might be pregnant. The ACR-SPR guideline does not specify or mandate such as a formal standard. However, it does recommend that all facilities specify in their policies which procedures require a pregnancy test in normal circumstances.
Because patients may be in the Radiology suite for prolonged periods (either for prolonged procedures or simply waiting for a procedure or for transport) some may become vulnerable to pressure-related injuries (eg. decubiti, compressive neuropathies) if attention is not paid to repositioning. There should always be a plan in place for overall nursing care of any patient sent to the Radiology area.
Patients Deteriorating During Prolonged Waits in Radiology
Patients often need to wait for tests or wait for transport back to their unit of origin. We have seen numerous examples of patients deteriorating while waiting for a procedure or waiting to be transported back after a procedure. Sometimes this is related to omission of critical medications like insulin or anticoagulants or antibiotics (see the section above on medication errors in the Radiology suite). Other times it may be related to inadequate monitoring (eg. patients on PCA or opioids via other routes).
Our March 13, 2012 Patient Safety Tip of the Week “Medical Emergency Team Calls to Radiology” highlighted a series of papers by Lora K. Ott and colleagues (Ott 2012, Ott 2011a, Ott 2011b) on events in the Radiology suite that required medical emergency team calls. The nature of the events in the radiology suite were primarily cardiac in 41%, respiratory in 29%, and neurological in 25% and most required a higher level of care after the event. 44% of the calls involved patients undergoing CT scan and 22% MRI scanning. That should not be surprising, given our many prior articles on safety issues in the radiology suite. During either procedure the patient is relatively isolated from monitoring staff for periods of time. In addition, sedation may be used to facilitate completion of some of those studies. Dislodging of catheters, tubes and lines during transfer to the CT/MRI platforms could also play a role. Also, the nature of the underlying condition necessitating the CT or MRI scan may also predispose these patients to the types of deterioration seen.
Transport of ICU patients to the radiology suite has for a long time been known to be hazardous. In our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” we noted a paper by Smith et al (Smith 1990) which reported adverse events during 34% of all ICU transports. Specifically, transport of ICU patients to the CT suite was associated with a 71% incidence of adverse events. Adverse events included disconnection of monitoring equipment, interruption of vasoactive medication drips, unintentional extubations, etc.
So that brings us back to another of our favorite topics – the handoff. In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” we discussed how the structure and format of handoffs needs to be tailored to the specific situation. The “Ticket to Ride” concept (see our Patient Safety Tips of the Week for April 8, 2008 “Oxygen as a Medication” and November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”) is a tool ideally suited for the radiology suite. It was originally developed for patients on oxygen therapy needing transport to radiology since studies had shown over 50% of such transports resulted in patients running out of oxygen. However, this concept addressing handoffs has been expanded to include attention to medication management, suicide risk, wandering risk, etc. in patients transported to radiology or other sites within the hospital. Our March 13, 2012 Patient Safety Tip of the Week “Medical Emergency Team Calls to Radiology” has some good suggestions about what should be included in your “Ticket to Ride” transport handoff tool.
This really fits into the concept of having a well thought out plan before sending patients to the Radiology suite. We must anticipate what sorts of problems the patients might encounter and take steps to mitigate the risks of those problems.
There are, of course, issues specific to radiology as well. These often pertain to use of contrast agents. This is especially likely to occur when there is inadequate information about previous allergies or renal function. Sometimes patients cannot provide the information about their other medications (eg. metformin) or whether they have an allergy to contrast, or whether they have impaired renal function. Hence it is critical to review the medical record for these issues and appropriately assess labs to ensure that results of current tests of renal function are available.
There have also been numerous cases where the wrong type or wrong dosage of a contrast agent has been injected during myelography with disastrous results, often because of inadequate labeling or storage. And we noted above the issue of unlabeled syringes or basins is as big an issue in radiology as it is in the OR such as the unfortunate case a few years ago where a patient was inadvertently given the antiseptic skin prep solution, chlorhexidine, instead of contrast media intraarterially (ISMP 2004).
Mishandling or Mislabeling of Specimens
More and more biopsy and tissue specimens are coming from the Radiology suite rather than the OR these days. Such specimens are prone to a variety of errors in mishandling, mislabeling, switched specimens, or simply lost specimens. For insight into some of the issues around such errors see some of our other columns on errors related to laboratory studies:
Safety in the MRI unit is a whole topic unto its own. We refer you to our prior columns on patient safety issues related to MRI:
The only additional recent study related to MRI safety we’d like to note is one that used a ferromagnetic detection system to detect implants and other objects (Shellock 2013). This system has the potential to be used in screening of patients prior to MRI.
Radiation Hazard to Patients
Though not the focus of today’s column, we have done numerous columns on the issues related to the safety hazards of ionizing radiation (see the list at the end of today’s column). But there have been several recent developments regarding reducing the dose of ionizing radiation and thus reducing the potential downstream risk of cancer. Researchers at Johns Hopkins (Pindrik 2013) found that limited-sequence head CT scanning provided adequate and accurate diagnostic information in children with shunted hydrocephalus. They were able to demonstrate that consistent sequences of 7 CT slices (instead of the typical 30-40 slices taken) were able to demonstrate the diagnostic information needed. This resulted in a 92% reduction of radiation dose. Use of this type of thinking should be applied to many other CT procedures to determine how many and which slices are necessary for adequate diagnosis.
Another paper (John 2013) reported on a checklist for pediatric digital radiography safety as part of the Image Gently® campaign. The checklist was developed to help radiology technologists obtain digital radiographs with patient safety in mind. Today not only CT scanning but most imaging uses digital techniques. With digital techniques radiology technologists no longer have the ability to visually determine whether there was overexposure or underexposure like they could in the old film screen world. New grads may be familiar with the new image technologies but older technologists may not. So the checklist and companion educational tools were developed and piloted. The actual checklist is included in the article or is separately downloadable from the Image Gently® website. The latter has great resources on its Image Gently and Digital Radiography - Quality Improvement page, including links to the Digital Radiography Safety Checklist itself and the implementation manual. The checklist can also be used as a quality improvement audit tool. The Image Gently® website also has a downloadable spreadsheet tool for data collection to be used in your quality improvement activities. Note that the John paper also has a good discussion on checklist design (do-and-verify vs. read-and-do, keep it short, include only critical steps, etc.).
Our June 2010 What’s New in the Patient Safety World column “WHO Checklist for Radiological Interventions” highlighted a checklist developed specifically for radiological interventions. That WHO Surgical Safety Checklist: for Radiological Interventions ONLY checklist is downloadable here. Meanwhile, a group of Canadian interventional radiologists (Athreya 2013) developed their own safety checklist for interventional radiological procedures, modeled after the WHO Surgical Safety Checklist. Note that their checklist also includes items that the ward to which the patient is being transferred has been notified and that aftercare instructions have been communicated to the patient. The checklist is scanned into the medical record after the procedure and can be utilized for quality improvement audits as well. They note the importance of regular review and revision of the tool. Such review led to a revision that made review of any prior imaging necessary (note our Patient Safety Tips of the Week for August 27, 2013 “Lessons on Wrong-Site Surgery” and January 1, 2013 “Don’t Throw Away Those View Boxes Yet” discussed the importance of reviewing imaging studies in avoiding wrong site surgery).
On the adult side, Image Wisely® has begun to present the Image Wisely Radiation Safety Case, a series of free online and mobile-compatible educational offerings in conjunction with the American College of Radiology (ACR). They plan to run six radiation safety cases over a year.
Also, this month’s AHRQ Web M&M has two columns pertinent to the issues of balancing risks vs. benefits when considering diagnostic imaging that uses ionizing radiation. One is an excellent interview (Wachter 2013) with Rebecca Smith-Bindman, MD, whose work on reducing unnecessary exposure to ionizing radiation we have mentioned in several of our prior columns. The other is a perspective by Italian radiologist Antonio Pinto (Pinto 2013)
We bet you never thought what a potentially dangerous area the Radiology suite can be! The Radiology suite is a great place to include in your Patient Safety Walk Rounds and an excellent place to choose for doing a FMEA (Failure Mode and Effects Analysis) exercise.
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on the “Ticket to Ride” concept:
Some of our previous columns on the issue of radiation risk:
Abujudeh H, Kaewlai R, Shah B, Thrall J. Original Research. Characteristics of Falls in a Large Academic Radiology Department: Occurrence, Associated Factors, Outcomes, and Quality Improvement Strategies. American Journal of Roentgenology 2011; 197: 154-159
PPSA (Pennsylvania Patient Safety Authority). Falls in Radiology: Establishing a Unit-Specific Prevention Program. Pa Patient Saf Advis 2011; 8(1): 12-17
PPSA (Pennsylvania Patient Safety Authority). Radiology Falls Risk Assessment Tool. 2011
United States Pharmacopeia (USP) MEDMARX® Data Report “A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services”. 2006
Darves B. Imaging hand-offs: Tips to help prevent medication errors. ACP Observer 2006; April 2006
ISMP (Institute for Safet Medication Practices). Loud wake-up call: Unlabeled containers lead to patient's death.ISMP Safe Medication Safety Alert! Acute Care Edition.December 2, 2004
PPSA (Pennsylvania Patient Safety Authority). Medication Errors Occurring in the Radiology Services Department. Pa Patient Saf Advis 2009; 6(2): 46-50
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
PPSA (Pennsylvania Patient Safety Authority). Applying the Universal Protocol to Improve Patient Safety in Radiology Services. Pa Patient Saf Advis 2011; 8(2): 63-9
PPSA (Pennsylvania Patient Safety Authority). Radiology Services Patient and Procedure Identification Assessment Tool. 2011
WHO Surgical Safety Checklist: for Radiological Interventions ONLY.
Athreya S, Mikhail M, Reis Welsh S, et al. Patient Safety in Interventional Radiological Procedures: Safety Checklists and Protocols. Journal of Patient Safety 2013; 9(3): 119–121
Gibson J, Taylor DH. AHRQ Web M&M Case & Commentary “The Dangerous Detour.” June 2003
Penzias A. Implementing a Protocol to Protect Suicidal Patients in Radiology.
Journal of Radiology Nursing 2013; 32(2): 105, June 2013
Penzias A, Martino J, Salazar G. The Suicidal Patient in Radiology. Suicide Risk Intervention in Imaging. (story board)
ACR (American College of Radiology). ACR–SPR Practice Guideline For Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation. Revised 2013
Ott LK, Pinsky MR, Hoffman LA, et al. Medical emergency team calls in the radiology department: patient characteristics and outcomes. BMJ Qual Saf 2012; published online ahead of print March 2, 2012
Ott LK, Hoffman LA, Hravnak M. Intrahospital Transport to the Radiology Department: Risk for Adverse Events, Nursing Surveillance, Utilization of a MET, and Practice Implications. Journal of Radiology Nursing 2011; 30(2): 49-54
Ott LK, Hravnak M, Clark S, Amesur NB. Patients’ Instability, Emergency Response, and Outcomes in the Radiology Department.
Am J Crit Care November 2011; 20(6): 461-469
Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3): 278-281
Shellock FG, Karacozoff AM. Detection of Implants and Other Objects Using a Ferromagnetic Detection System: Implications for Patient Screening Before MRI. American Journal of Roentgenology 2013; 201: 720-725
Pindrik J, Huisman TAGM, Mahesh M, Tekes A, Ahn ES. Analysis of limited-sequence head computed tomography for children with shunted hydrocephalus: potential to reduce diagnostic radiation exposure: Laboratory investigation. Journal of Neurosurgery: Pediatrics 2013; Posted online on 20 Sep 2013.
John SD, Moore QT, Herrmann T, Don S, et al. The Image Gently Pediatric Digital Radiography Safety Checklist: Tools for Improving Pediatric Radiography. J Am Coll Radiol 2013; 10: 781-788.
Image Gently®. Image Gently and Digital Radiography - Quality Improvement.
Image Gently® Digital Radiography Safety Checklist
Implementation Manual. Image Gently® Digital Radiography Safety Checklist.
Image Gently® Digital Radiography Safety Checklist Spreadsheet for Quality Improvement Data Collection.
Image Wisely®. Image Wisely Radiation Safety Case.
Wachter R (ed.). AHRQ WebM&M. Perspectives in Safety. Safety in Radiology. Interview “In Conversation with…Rebecca Smith-Bindman, MD.” AHRQ WebM&M October 2013
Pinto A. AHRQ WebM&M. Perspectives in Safety. Safety in Radiology. Perspective.
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
We have done multiple columns on the prevention and management of delirium in the ICU (and elsewhere) and the integration of such approaches with other intervention programs in the ICU (see the list at the end of today’s column). We’ve also done multiple columns discussing ICU interventions that improve time on ventilators, ICU length of stay, etc. Our December 2010 What’s New in the Patient Safety World column “The ABCDE Bundle” discussed one such bundle, the “ABCDE bundle” (Vasilevskis 2010). The ABCDE acronym stands for “Awakening and Breathing Coordination”, “Delirium monitoring”, and “Exercise/Early mobility”.
In January 2013 the American College of Critical Care Medicine published new guidelines on the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit (Barr 2013a). We’ll refer to these as PAD. The guidelines were developed after a comprehensive review of the literature to determine evidence-based best practices for prevention and management of pain, agitation and sedation, and delirium in ICU patients. The released guidelines apply to adult patients and there is a separate guideline in the works for pediatric patients.
An entire recent supplement of Critical Care Medicine was dedicated to “Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult ICU Patients” and related issues. One of the papers in that supplement discusses the synergistic benefits of implementing the PAD guidelines in conjunction with other ICU strategies like spontaneous awakening trials, spontaneous breathing trials, early mobility programs, and sleep hygiene programs (Barr 2013b).
PAD uses validated tools to regularly assess ICU patients regarding pain, agitation/sedation, and delirium. Results of the assessments are recorded in the medical record and are incorporated into the daily discussions on interdisciplinary ICU rounds, with ICU teams discussing each individual patient’s scores and regimens, the current and target scores, and then incorporated into a treatment plan for each individual patient.
For pain, a numerical rating scale (NRS) is used for patients who are communicative. For those unable to communicate pain, use of a behavioral pain scale (BPS) or the Critical-Care Pain Observation Tool (CPOT) is recommended. The PAD mandates that assessments for pain using these tools be done at least 4 times per nursing shift (more often if necessary) and the results documented in the medical record.
For agitation/sedation PAD determined that the RASS (Richmond Agitation-Sedation Scale) or the SAS (Sedation-Agitation Scale) are the most valid and reliable assessment tools. These are also done at least 4 times per nursing shift (more often if necessary).
For delirium, the CAM-ICU or the ICDSC (Intensive Care Delirium Screening Checklist) are recommended as the most valid and reliable monitoring tools. These are done at least every nursing shift and more often if necessary.
Pain management is usually considered first, particularly since it has a big impact on management of the other conditions. If pain control is optimized it may reduce the need for sedation. Similarly, pain is one of the common contributing factors to delirium. They cite several studies showing that an “analgesia first” approach (minimizing the need for sedation) is associated with reductions in duration of mechanical ventilation and shorter ICU lengths of stay. It notes that pain is not just seen in surgical ICU patients but that medical patients frequently have pain in the ICU. Procedure-related pain is common and should be managed pre-emptively. PAD calls for prompt management of pain (within 30 minutes of its recognition) and pain should be assessed again 30 minutes after an intervention to assess efficacy of that intervention.
While PAD is generally nonproscriptive regarding specific medications, it does recommend opiates as the first line therapy for non-neuropathic pain (though it notes that adjunctive drugs such as NSAID’s or acetaminophen may be used to help lower the dose of opioids). PAD recommends gabapentin or carbamazepine for neuropathic pain. They suggest that neuraxial analgesia be restricted to those with rib fractures and certain abdominal procedures.
Sedation should be used only as needed. If pain is adequately managed many patients may need no sedation at all. We all recognize there is a tendency to oversedate ICU patients on ventilators (see also our March 2010 What’s New in the Patient Safety World column “If Sedation Vacations Work, Why Not Eliminate Sedation All Together?”). And when sedation is needed it should be titrated to a light level where the patient is able to maintain interaction with his surroundings and follow simple commands. They note that light sedation could be achieved by either targeted sedation strategies or by daily sedation holidays. Again, they are not proscriptive regarding specific medication recommendations though they do note that “there is a growing body of evidence that the use of IV benzodiazepines for sedation of ICU patients, specifically midazolam and lorazepam, is associated with worse ICU outcomes than sedation with nonbenzodiazepines (specifically propofol and desmedetomidine)”. They discuss integration of the PAD interventions with other interventions like spontaneous breathing trials, spontaneous awakening trials, and daily sedation interruptions.
Management of delirium starts with removing many of the potential contributing factors we have often discussed (certain medical conditions, preexisting cognitive deficits, withdrawal states, untreated pain, sedating drugs, sleep deprivation, restraints, Foley catheters, immobilization, etc.). If the delirium persists despite removal of such factors they recommend nonpharmacological interventions like reorienting activities, ensuring patients have their eyeglasses and hearing aids, maintaining sleep-wake cycles, and early mobilization. They have a good discussion of ways to promote sleep in the ICU, including clustering of ICU patient care activities to minimize frequent patient arousals. Controlling light and noise are important. They recommend raising the window blinds during the daytime, avoiding excessive daytime naps, minimizing caffeine use in the evening, and use of earplugs. Early mobilization is encouraged, getting the patient up out of bed even while being mechanically ventilated.
They summarize the conflicting literature on use of both traditional and atypical antipsychotic drugs and really make no recommendation regarding their use (see also our September 2013 What’s New in the Patient Safety World column “Disappointing Results in Delirium”).
The authors go on to present data demonstrating that there appear to be synergistic effects from implementing multiple components of not only the PAD bundle but also the other interventions noted above. The results show benefits in both patient outcomes and overall costs. Importantly, the authors note that there is an evidence base supporting improved outcomes from the various interventions individually and in combination but that, to date, there is no measurement of outcomes from implementation of the entire PAD program.
Regarding implementation strategies, they stress that implementing the assessment tools first and demonstrating these are done reliably and consistently is important. Those assessments should be incorporated into daily ICU rounds, ICU goal sheets, checklists, order sets and the overall patient care plan.
The PAD guidelines are very promising and the early experiences seem to have been quite positive. However, we look forward to seeing results of studies that demonstrate improved outcomes and lower costs after implementation of the entire PAD bundle, with or without intergration with the other strategies. Recall a lesson in our December 2010 What’s New in the Patient Safety World column “Bad Bundle? Or Not?”: don’t assume that interventions which are combined will necessarily produce more improvement. That column discussed a randomized controlled trial of a bundle of interventions in colorectal surgery that had been shown to reduce surgical site infections in studies where they were evaluated individually (Anthony 2010). They went into their study expecting to see at least an additive and perhaps synergistic effect of combining interventions. It is counterintuitive to think that combining interventions that proven efficacy individually would actually lead to worse outcomes. But that is exactly what they saw in their study.
Nevertheless, the PAD guidelines are practical and have a sound evidence base and it makes a whole lot of sense to implement them in your ICU’s even while we are awaiting confirmation of their collective efficacy.
Some of our prior columns on delirium assessment and management:
Vasilevskis EE, Ely EW, Speroff T, et al. Reducing Iatrogenic Risks: ICU-Acquired Delirium and Weakness—Crossing the Quality Chasm. Chest 2010; 138: 1224-1233 November 2010
Barr J, Fraser GL, Puntillo K, et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine 2013; 41(1): 263–306
Critical Care Medicine Supplement. Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult ICU Patients. Critical Care Medicine 2013; 41(9) (Supplement 1): S1-S145 September 2013
Barr J, Pandharipande PP. The Pain, Agitation, and Delirium Care Bundle: Synergistic Benefits of Implementing the 2013 Pain, Agitation, and Delirium Guidelines in an Integrated and Interdisciplinary Fashion. Critical Care Medicine 2013; 41(9): S99-S115
Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an Evidence-Based Bundle for Preventing Surgical Site Infection. A Randomized Trial. Arch Surg. Published online November 15, 2010. doi:10.1001/archsurg.2010.249
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
Joint Commission’s most recent Sentinel Event Alert (TJC 2013) addresses preventing unintended retained foreign objects. Interesting how the terminology has gone full circle. We used to always use the term “retained foreign objects” (RFO’s) but then some of the literature pushed toward the term “retained surgical items” (RSI’s) to distinguish those items inadvertently left behind during surgery from other retained foreign bodies like broken catheter guide wires. Now TJC is using the acronym “URFO” for unintended retained foreign objects.
TJC’s sentinel event database includes 772 incidents of URFO’s from 2005 to 2012, including 16 deaths. These, of course, are a significant underestimate since not all such cases get reported to TJC. They note that 95% of the incidents result in additional care or extended hospital stay and additional costs (citing a Pennsylvania Patient Safety Authority estimate of $166,000 average cost for a URFO).
Though they do discuss risk factors for URFO’s (eg. emergent cases, unexpected change in procedure, intra-abdominal surgery, obesity, multiple procedures, multiple surgical teams, long case duration, multiple staff turnovers during the procedure), the root causes are probably more important. Root causes include problems with the hierarchy and intimidation, poor communication, failure to follow policies and procedures, lack of policies and procedures, and lack of education of staff.
They note that the two most frequently used methods to avoid URFO’s, surgical “counts” and cavity “sweeps”, are both prone to human error. Despite this, they noted that standardization and other improvements to “counting” have reduced the risk of URFO’s in various studies. But they note that leadership must be committed and the culture of safety must support workers speaking up when they identify unsafe conditions.
The Sentinel Event Alert goes on to outline recommendations for the counting procedure and wound opening and closing procedures, largely taken from the “NoThing Left Behind®” campaign (Gibbs 2013) and AORN guidelines (Goldberg 2012) that we discussed in our June 12, 2012 Patient Safety Tip of the Week “Lessons Learned from the CDPH: Retained Foreign Bodies”. They discuss when intra-operative imaging studies should be done and mention some of the newer technologies that might supplement the manual count. They also recommend strategies to improve communication (eg. briefings, debriefings, CRM training, speaking up, etc.).
We’ve already done several columns on retained surgical items (listed below). We encourage you to read them because they contain a wealth of information on the topic.
Since our last column on RSI’s/RFO’s there have been a few more articles that are relevant. One very interesting one addressed the issue of retained surgical sponges from an engineering perspective (Anderson and Watts 2013). They note that most healthcare organizations have approached the issue with counting methodologies that are inherently flawed or technological solutions that are quite expensive. So they applied engineering problem-solving methodology to address the issue. The first step is putting the problem into a statement that is not biased and a need statement. The engineer then identifies constraints and potential solutions and formulates specifications. The latter include metrics that can be tested and a weight is assigned to each specification based upon is perceived importance. Brainstorming and analyzing alternative approaches follows.
The problem statement they came up with was “The accidental retention of currently available surgical sponges necessitates additional surgery and adds expenses to surgical procedures.” Our traditional approach has always been that we need to account for the sponges by manually counting or using some other technology that accounts for the sponges. The engineers, on the other hand, conclude that the only way to eliminate the dangers is to alter the sponge itself! Hence their solution was to pursue development of a bioresorbable surgical sponge. The article then goes on to describe the next steps in that pursuit.
It is most interesting that the same biases that we see in diagnostic error (eg. anchoring, premature closure, familiarity, etc.) come into play in our approach to patient safety issues. Read the Anderson and Watts article! This fresh perspective that engineering problem-solving methodology brings is most encouraging.
In our June 12, 2012 Patient Safety Tip of the Week “Lessons Learned from the CDPH: Retained Foreign Bodies” we noted several unusual items found as retained foreign bodies (a blue towel, a cautery tip, a Kerlix bandage). A couple other recent resources point out some unusual factors contributing to RFO/RSI’s. Ipaktchi and colleagues described a “near-miss” in which a piece of labeling tape from a surgical instrument broke off and was found in the wound before closure (Ipaktchi 2013). They note that over the years there had been a trend away from engraving or etching surgical instruments to using tape labeling or plastic resin dipping for instruments. The latter two techniques spare the smooth surface of the instruments and add color coding. But with repetitive use and repetitive cycles of cleaning and sterilization these labels may become fragile or loose and break off. Since they are not radiopaque they would easily escape detection and have the capacity to cause all the problems we see with other retained foreign bodies. They suggest that more modern labeling techniques, like laser engraved QR codes or one dimensional bar codes, will replace current techniques. They note that the FDA’s plans for medical device tracking will likely facilitate this change. They note that such labeling will not only improve tracking of instruments in surgery but will also allow tracking of instrumentation processing cycles and adherence to maintenance protocols.
The other was from the investigation of a RFO reported by the California Department of Public Health (CDPH CA00235788). In this case the retained foreign object was a “fish”. No, not the kind of fish that swims in water but rather a Glassman viscera retainer, which is a fish-shaped soft flexible device that folds into a roll and is used to shield from nicks and punctures. All the “counts” in the case were reported to be correct. But apparently when the “fish” was added to the surgical field it was not added to the count verbally or on the count board (see our January 8, 2013 Patient Safety Tip of the Week “More Lessons Learned on Retained Surgical Items” regarding addition of items to the surgical field). In addition, the “fish” apparently has a string attached to promote retrieval but that string had been cut by the surgeon. Guidelines for surgical sponges have always emphasized the importance of not cutting or altering the sponges. Obviously the same should apply to other things, like the “fish”.
We’re always amazed at the increasing variety of items showing up as retained foreign objects. The Joint Commission Sentinel Event Alert reminds us that the problem of retained foreign objects and retained surgical items is not going away. While we wait for innovative solutions like those described by Anderson and Watts and by Ipaktchi and colleagues, we need to focus on best practices like those outlined in the “NoThing Left Behind®” campaign (Gibbs 2013) and AORN guidelines (Goldberg 2012).
Our prior columns on retained surgical items (RSI’s) and retained foreign bodies (RFO’s):
TJC (The Joint Commission). Sentinel Event Alert. Preventing unintended retained foreign objects. Issue 51 October 17, 2013
NoThing Left Behind® Campaign.
Gibbs VC. POLICY: NoThing Left Behind®: Prevention of Retained Surgical Items Multistakeholder Policy. NoThing Left Behind®. October 2013
Goldberg JL, Feldman DL. Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal 2012; 95(2): 205-219
Anderson DE, Watts BV. Application of an Engineering Problem-Solving Methodology to Address Persistent Problems in Patient Safety: A Case Study on Retained Surgical Sponges After Surgery. Journal of Patient Safety 2013; 9(3): 134–139
Ipaktchi K, Kolnik A, Messina M, Banegas R, Livermore M, Price C. Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis. Patient Safety in Surgery 2013; 7: 31 (30 September 2013)
CDPH (California Department of Public Health). Event ID CA00235788
November 12, 2013
More on Inappropriate Meds in the Elderly
We’ve done many prior columns on Beers’ List and medications which may be inappropriate in the elderly. In our December 2011 What’s New in the Patient Safety World column “Beers’ Criteria Update in the Works” we noted that the original Beers’ List and subsequent updates were primarily consensus-based rather than truly evidence-based. But the new updated version is much improved in that regard since there has been an extensive review of the evidence in the new work effort.
One of the quality metrics reported by CMS for its Medicare Advantage plans is the percentage of elderly patients prescribed high-risk medications. The list of those medications is taken largely from Beers’ List. A recent study (Cooper 2013) compared rates reported by the health plans with rates calculated from Medicare Part D (pharmacy) claims and found significant underreporting by many Medicare Advantage plans. The accompanying editorial (Maciejewski 2013) points out that CMS regularly audits billing and payment data for such health plans but that the Cooper study highlights the need for audits on the quality metrics reported as well.
But the bigger question should be “Does focusing on PIM’s (potentially inappropriate medications) using administrative databases actually lead to improved patient outcomes and safety?” A recent study suggests it may not. In our March 2011 What’s New in the Patient Safety World column “Inappropriate Medications Often Start in the ICU” and our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?” we noted a study by Morandi and colleagues (Morandi 2011) that showed many of the PIM’s (potentially inappropriate medications) and AIM’s (actually inappropriate medications) which elderly patients were discharged on were actually initiated in the ICU. The same research group has now followed up on that study with a new one (Morandi 2013) that did clinical reviews to determine whether PIM’s were actually AIM’s. Their findings are very informative.
In 120 patients who survived ICU stays there were 250 PIM’s prescribed at hospital discharge. When a multidisciplinary team did clinical reviews of the PIM’s to determine whether such prescriptions were actually inappropriate, only 36% were deemed inappropriate. Moreover, the percentage deemed actually inappropriate varied greatly by medication category. Low percentages of opioids, antidepressants, and drugs causing orthostasis were deemed to be inappropriate. On the other hand, high percentages of anticholinergic drugs, atypical antipsychotics, benzodiazepines, non-benzodiazepine hypnotics, and muscle relaxants were deemed to be actually inappropriate.
Moreover, risk factors for being prescribed a PIM at discharge (seen in other studies and confirmed in this study) turned out not to be predictive of an AIM. They conclude that using lists of PIM’s as screening tools are likely to generate many false-positive flags or warnings and may ultimately lead to inappropriate clinical decisions or alert fatigue. They stress the importance of clinical context and the value of having a multidisciplinary team review the drugs for clinical appropriateness. They note that almost two-thirds of the AIM’s were initially begun in the ICU (where they may have been appropriate). Thus, medication reconciliation at every transition of care is important (eg. admission, ICU discharge, and hospital discharge). And efforts should focus on those categories that are most likely to be inappropriate at discharge (anticholinergic drugs, atypical antipsychotics, benzodiazepines, non-benzodiazepine hypnotics, and muscle relaxants).
However, another word of caution is in order. Though we focus heavily on the drugs appearing on Beers’ List, many of the adverse drug events (ADE’s) experienced by the elderly (and the not-so-elderly) are related to commonly prescribed drugs that are not on the list. A recent study from Australia (Miller 2013) looked at occurrence of ADE’s in adults aged 45 and older. They found that 11.6% of all patients experienced at least one ADE in the previous 6 months. While most ADE’s were mild or moderate, 11.8% were severe and 5.4% resulted in hospitalizations. Thirteen commonly prescribed drug classes accounted for 58% of all ADE’s and the list bore little resemblance to Beers’ List. Opioids were the most frequently implicated (8.2% of all ADE’s) and accounted for over 14% of the hospitalizations. ADE’s from salicylates and NSAID’s accounted for 12.2% of hospitalizations related to ADE’s.
In our December 2011 What’s New in the Patient Safety World column “Beers’ Criteria Update in the Works” we also noted multiple studies which demonstrated drugs not on Beers’ List are frequent causes of ADE’s. In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?”, we noted that the literature has been mixed on the ability of Beers’ List to predict adverse drug events (ADE’s). The STOPP criteria, on the other hand, identified potentially avoidable ADE’s impacting on hospitalization over twice as often as did Beers’ criteria and such ADE’s are extremely common (Hamilton 2011). Another study (Budnitz 2011) on emergency hospitalizations related to ADE’s concluded that drugs on Beers’ list account for only a small percentage of hospitalizations. In that study, 6.6% of the ADE-related hospitalizations were related to potentially inappropriate medications on Beers’ list and if digoxin is excluded this is reduced to only 3.17%. On the other hand, two thirds of the hospitalizations were related to only four medications or medication categories: warfarin/anticoagulants, antiplatelet agents, insulins, and oral hypoglycemia agents.
Whether the focus should be on Beers’ List drugs or other drugs, the importance of medication reconciliation at the time of discharge must be emphasized. But it is still problematic, for both patients and physicians. That is why many programs designed to prevent unnecessary rehospitalizations have focused on a phone call (or other contact) to the patient at 24-48 hours after discharge. Often that contact is made by a pharmacist since confusion about medications is very common once the patient gets home. A new study (Harris 2013) looked at medication changes that occurred during hospitalization in 95 elderly patients and patient compliance with those changes 3 days after discharge. They found high rates of adherence to new medications prescribed at discharge. However, the story was different for medications intended to be discontinued after discharge. Of antihypertensives discontinued, 25% of patients started them up again on return home. For analgesics, 88% of those discontinued were restarted by patients on return home. They also noted that 5% of medications which had been taken at home prior to admission were never included on the admission and subsequent hospital medication reconciliation lists. The study really highlights the value of the post-discharge phone call being done by a clinical pharmacist or a physician or nurse who can focus on clarifying the medications the patient should be taking.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Patient Safety Tips of the Week:
What’s New in the Patient Safety World columns:
The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012
Cooper AL, Kazis LE, Dore DD, et al. Underreporting High-Risk Prescribing Among Medicare Advantage Plans: A Cross-sectional Analysis. Ann Intern Med. 2013; 159(7): 456-462
Maciejewski ML, Hanlon JT. Underreporting Potentially Inappropriate Prescribing for Older Outpatients: Does It Matter? (Editorial)
Ann Intern Med 2013; 159(7): 496-497.
Morandi A, Vasilevskis EE, Pandharipande PP, et al. Inappropriate Medications in Elderly ICU Survivors: Where to Intervene? Arch Intern Med 2011; 171: 1032-1034
Morandi A, Vasilevskis E, Pandharipande PP, et al. Inappropriate Medication Prescriptions in Elderly Adults Surviving an Intensive Care Unit Hospitalization
Journal of the American Geriatrics Society 2013; 61(7): 1128–1134
Miller GC, Valenti L, Britt H, Bayram C. Drugs causing adverse events in patients aged 45 or older: a randomised survey of Australian general practice patients. BMJ Open 2013; 3:e003701 Published 10 October 2013 doi:10.1136/bmjopen-2013-003701
Hamilton H, Gallagher P, Ryan C, et al. Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Arch Intern Med 2011; 171(11): 1013-1019
Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. NEJM 2011; 365: 2002-2012
Harris CM, Sridharan A, Landis R, et al. What Happens to the Medication Regimens of Older Adults During and After an Acute Hospitalization? Journal of Patient Safety 2013; 9 (3): 150–153
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
One of our all-time most popular columns was our September 21, 2010 Patient Safety Tip of the Week “Dilaudid Dangers”. Though we have seen patient safety problems with all opioids, HYDROmorphone comes up more often than all the others. The major problem is misperception of the relative potency of HYDROmorphone. All too many healthcare professionals mistake HYDROmorphone as being equivalent to morphine when, in fact, HYDROmorphone is much more potent on a mg basis. While estimates of equipotency vary considerably in the literature, most now agree that 1 mg. of Dilaudid is probably the equivalent of at least 7 mg. of morphine. Chang and colleagues (Chang 2006) had noted several years ago that emergency room physicians and nurses who were hesitant to administer 7 to 10 mg. of morphine were not reluctant to administer 1 to 1.5 mg. of Dilaudid. They point out this is an illusion that less narcotic is being used with that Dilaudid dose.
ISMP Canada has been a leader in addressing the patient safety issues associated with HYDROmorphone. We’ve highlighted a series of articles from ISMP Canada in our Patient Safety Tips of the Week for September 21, 2010 “Dilaudid Dangers”and July 3, 2012 “Recycling an Old Column: Dilaudid Dangers” that have focused on HYDROmorphone safety (ISMP Canada 2004, ISMP Canada 2006, ISMP Canada 2012a, ISMP Canada 2012b).
Our October 2013 What’s New in the Patient Safety World column “Opioid Safety Actions and Resources” mentioned a study from ISMP Canada on deaths associated with medication incidents (ISMP Canada 2013a). The drug most frequently implicated on that list was HYDROmorphone.
Now a new safety bulletin from ISMP Canada (ISMP Canada 2013b) reports results of a targeted pilot intervention to improve HYDROmorphone safety. The study also highlights many of the difficulties and barriers encountered in implementing such interventions.
They looked at prior recommendations on HYDROmorphone safety and prioritized them according to a hierarchy of effectiveness and came up with 5 actions designed to improve system safety:
Each of the 5 participating hospitals completed at least one of the recommended actions but the average response was less than 50% of the achievable score for each category. The activities undertaken by the participating hospitals tended to be the ones that could be implemented most quickly and easily and those that were directly controlled by the pharmacy department. Workload issues were the most common barriers encountered.
None of the participating hospitals implemented the CPOE alert, with most citing concerns about alert fatigue as a potential barrier. However, including an alert on ADC’s about limiting initial doses of HYDROmorphone to 1 mg or less was more accepted.
The audits were generally felt to be quite positive. This was felt to be a valuable and simple intervention. In fact, some felt that doing them daily rather than weekly would be easier to remember. We would also like to emphasize that feedback after audits is usually most productive when such feedback occurs in close proximity to the events rather than being delayed.
Interestingly, system issues often interfered with implementation of some recommendations. These included not only workload issues but also bureaucracy issues (eg. materials for patient education were delayed because they had to be approved by the hospital communication department).
They note that because of concerns about alert fatigue it may be more practical to limit the dose of HYDROmorphone by using standardized order sets. We concur with that. Order sets, whether computerized or paper-based, can help steer away from using HYDROmorphone as well as helping avoid prescription of inappropriately high doses when it is prescribed.
In our July 3, 2012 Patient Safety Tip of the Week “Recycling an Old Column: Dilaudid Dangers” we noted knowledge gaps regarding HYDROmorphone uncovered by ISMP Canada in a nationwide survey of healthcare providers (ISMP Canada 2012a, ISMP Canada 2012b). There were especially knowledge gaps on differences in potencies of HYDROmorphone in various preparations (eg. oral vs. parenteral vs. subcutaneous) and gaps regarding the various slow-release forms. Some gaps in knowledge were also noted regarding the concepts of patients being either opioid-naive or opioid-tolerant. And the biggest gaps in knowledge about HYDROmorphone appeared to be related to the pharmacological aspects. In particular, knowledge appeared to be limited regarding the duration of action of the various forms of HYDROmorphone and their relationship to the duration of action of naloxone. That, of course, is relevant to the phenomenon of “renarcotization” in which the reversal effect of the narcotic antagonist disappears while there is still substantial opioid on board. Also, there were gaps in knowledge regarding dosing of HYDROmorphone in patients with various comorbidities. Many respondents incorrectly thought that higher doses were needed in obese patients. Many also did not understand that lower doses should be used in patients with COPD, obstructive sleep apnea, the elderly, and those taking benzodiazepines. They also identified knowledge gaps related to the HYDROmorphone medication use process, particularly related to the proper steps for verifying orders, doing dose calculations, and programming IV pumps.
Our regular readers know that we strongly recommend that you limit the number of opioids to be used in your PCA pumps. You can standardize PCA on morphine and restrict prescription of other opioids to members of your pain management service or providers who have been specifically credentialed and privileged to order other opioids. The same argument could probably be made for opioids given via other routes.
Keep in mind that there may be legitimate indications for using HYDROmorphone in preference to morphine. For example, you may have a patient who gets pruritis with morphine, in which case HYDROmorphone may be an acceptable alternative.
Look-alike/sound-alike (LASA) issues also continue to occur, in which hydromorphone and morphine are mixed up. In fact, this is said to be one of the most frequent drug pairs involved in LASA errors. Use of tall man lettering (HYDROmorphone) is advised but, frankly, many healthcare workers still mistakenly assume that HYDROmorphone is an equipotent form of morphine. An outstanding published RCA (root cause analysis) done by ISMP Canada on a fatal Dilaudid overdose highlighted not only the fact that hydromorphone sounds like morphine but at that time also came in packaging that looked similar to that for morphine. Even this year ISMP’s Michael Cohen (Cohen 2013) showed how one manufacturer’s 1 mL vials of HYDROmorphone closely resemble its vials of morphine sulfate 5 mg/mL, especially when the caps are removed. ISMP recommends that the two vials not be used in the same facility, if possible. If they are, pharmacies should consider not dispensing both vials to the same patient-care area.
And, of course, the most important patient safety intervention with all opioids is appropriate patient monitoring (see the list below of all our columns on monitoring patients on opioids).
From today’s column and our previous Patient Safety Tips of the Week for September 21, 2010 “Dilaudid Dangers”and July 3, 2012 “Recycling an Old Column: Dilaudid Dangers” here are some strategies you should consider to reduce the risk of Dilaudid (and other opioid) adverse events:
Our prior columns on patient safety issues related to Dilaudid/HYDROmorphone:
Our prior articles pertaining to long-acting and/or extended release preparations of opioids:
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
Chang AK, Bijur PE, Meyer RH, et al. Safety and Efficacy of Hydromorphone as an Analgesic Alternative to Morphine in Acute Pain: A Randomized Clinical Trial.
Ann Emerg Med 2006; 48: 164-172
ISMP Canada. Event Analysis Report: Hydromorphone/Morphine Event - Red Deer Regional Hospital. Red Deer, Alberta. 2004
ISMP Canada. Shared Learning – Reported Incidents Involving Hydromorphone. ISMP Canada Safety Bulletin. December 28, 2006
ISMP Canada. Identifying Knowledge Deficits Related to HYDROmorphone. ISMP Canada Safety Bulletin 2012; 12(7): 1-4 June 27, 2012
ISMP Canada. Report to Health Canada. Hydromorphone Knowledge Assessment
Survey Results. April 2012
ISMP Canada. Deaths Associated with Medication Incidents: Learning from Collaborative Work with Provincial Offices of the Chief Coroner and Chief Medical Examiner. ISMP Canada Safety Bulletin 2013; 13(8): 1-5
ISMP Canada. Safeguards for HYDROmorphone–Results of a Targeted
Demonstration Project. ISMP Canada Safety Bulletin 2013; 13 (10): 1-5 November 4, 2013
Cohen MR. Medication Errors. Nursing 2013; 43(3): 72
November 26, 2013
Missed Care: New Opportunities?
This month there was an online first study (Ausserhofer 2013) and editorial (Wakefield 2013) in BMJ Quality and Patient Safety on a topic rarely discussed in the literature: missed nursing care. This is defined as any aspect of required care that is omitted either in part or in whole or delayed. We all, of course, have seen many consequences of such missed care when we do root cause analyses (RCA’s) of adverse events – the patient who fell on the way to the bathrrom after his hourly rounding/toileting session was missed, the patient who developed a decubitus after 4 hours elapsed between turnings, the patient who attempted suicide when her q15minute check was delayed for 30 minutes, the patient in whom recognition of clinical deterioration was delayed because vital sign checking was delayed, and many others. And how often have you watched someone take away an untouched lunch or dinner tray from a patient?
But the concept of missed care as a potential contributor to adverse patient events as an entity needing further research can be attributed to Beatrice Kalisch, RN, PhD. In 2006 (Kalisch 2006) she first brought examples of commonly missed nursing care that have been associated with adverse patient outcomes. (Make no mistake: the root causes of missed nursing care extend well beyond nursing and those factors put nurses in the position of having to prioritize care, leaving some care undone or delayed). Prior to 2006 there was virtually nothing in the literature about missed nursing care and its occurrence was described as “undiscussable” (Kalisch 2009a).
Kalisch did qualitative studies of hospital nursing staff using focus group interviews and developed a tool, the MISSCARE survey, to measure missed nursing care (Kalisch 2006, Kalisch 2009a). We are not talking here about occasionally missed or delayed nursing care but rather regularly missed nursing care. Kalisch and colleagues found nine elements of regularly missed nursing care that have the potential to impact patient outcomes:
They went on to identify 7 themes as to the reasons for missed care:
Given the incredible demands we place on our nursing staffs it is not surprising that some care goes undone or delayed. Under such circumstances nurses obviously prioritize which aspects of care to perform and which to delay or omit entirely. Understanding the thought processes involved in such prioritization is important.
Ambulation is one aspect of care often omitted. Early ambulation is important in reducing length of stay, fostering discharge to home rather than institutions, reducing the risk of delirium and other complications. Yet ambulation is often perceived as time-consuming. In some of Kalisch’s original focus groups nurses often thought that nursing assistants were doing patient ambulation but nursing assistants noted they seldom ambulated patients. Interestingly, on some units ambulation was done more frequently because the physicians asked whether their patients were being ambulated.
Turning is another aspect of nursing care that is often delayed. We suspect that since Kalisch’s original work in 2006 this may have improved since a variety of regulatory and pay for performance standards have increased hospitals’ focus on preventing decubiti. Now when you walk into the room of a patient identified as being at risk for decubiti you typically see a clock on a white board that shows when the patient was last turned. But when circumstances get hectic there may still be delays in turning patients.
Delayed or missed feedings are common as we noted in the first paragraph. Many patients ultimately are undernourished during their hospital stay, with potential adverse consequences.
Note that there are solutions other than using nurses for some of the “nursing care” issues. We have often recommended having dedicated “teams” of appropriately trained individuals for regular turning of patients at risk for decubiti, or for ambulating patients, or for feeding patients. Such may be more practical at larger hospitals and may not be feasible at small hospitals.
Patient education, discharge planning, and providing emotional support are commonly inadequately carried out. All are obviously important in transitioning patients to the next level of care and helping avoid rehospitalization. Yet all are perceived as time-consuming activities that tend to be prioritized to lower levels.
Patient hygiene includes bathing, mouth care, changing bed linens, etc. Again, these are often perceived as time-consuming activities that may be prioritized to lower levels.
Documentation of I&O’s (intake and output) may be inadequate for several reasons. Sometimes the food trays are removed before a nurse could document what was taken in by the patient. Or a patient may have gone to the bathroom without staff help and voided an unmeasured amount of urine. Also keep in mind that we physicians are often ignorant of the time required for such documentation and often order “I&O” indiscriminately. There are many patients in whom I&O’s are not needed at all and others in whom they are important only for a few days.
The last category, “surveillance”, is a little harder to define. But clearly a nurse’s “gestalt” of a patient is important in identifying patients who are deteriorating or otherwise at risk for potentially preventable complications. We noted in our March 2012 What’s New in the Patient Safety World column “Value of an Expanded Early Warning System Score” that some MEWS have added scoring for the nurse’s subjective impression of a patient’s status, an addition we strongly support. But in Kalisch’s original focus groups some nurses noted there were some patient rooms, often those most remote from the nursing station, that were entered much less often than others.
Probably more important than the categories of missed care are the reasons for missed care. As you’d expect having “too few staff” was the first response given in most of Kalisch’s focus groups. There, of course, are many studies that have linked adverse patient outcomes and preventable complications to inadequate nursing staffing. And it is not just the staff-to-patient ratio that is important. You need to take into account patient acuity and unexpected heavy work demands.
But even when nurse:patient ratios are “acceptable” there may be additional factors that prevent nurses from carrying out all regular aspects of nursing care. In our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” we noted work done by researcher Pattti Hamilton (RWJF 2009) highlighting the many additional activities nurses get stuck doing on weekends because of inadequate non-nursing staffing. Sometimes the nurses end up doing tasks such as transporting patients or even mopping floors. There is also less dietary and nutrition support, pharmacy and imaging services, physical therapy, patient teaching, and social services. She also points out that they may spend more time on the phone trying to track down doctors on weekends. So nurses end up doing many more tasks that they do not normally perform during regular “day” hours and they do not have as much time to do patient care and bedside nursing.
A somewhat related reason for missed care is poor use of existing staff resources. For example, there may be too few nursing assistants or aides. But this also includes supplies and equipment, medications, and other non-human resources. Kalisch has pointed out that experience levels of staff may vary from shift to shift and that issues with orientation and handoffs are also contributing factors. In a subsequent concept paper (Kalisch 2009b) Kalisch and colleagues developed a Missed Nursing Care Model which highlights teamwork and communication issues as one of three major antecedents to missed care.
One critical factor is the time required for a nursing intervention. As we noted above, the perceived time-consuming nature of some aspects of care (ambulation, bathing, feeding, teaching, discharge planning, emotional support) often leads to lower prioritization. In some of Kalisch’s work nurses noted they were often reluctant to start some of these activities because they felt they might get called away for other needs.
But the next group of reasons for missed care are common reasons for suboptimal outcomes in any organization or industry. One is the “It’s not my job syndrome”. For example, nurses often felt a task was no longer their responsibility once it was delegated to a nursing assistant. Often they would defer a task to the assistant even when they could have done the task much more efficiently themselves. Similarly, the assistants or aides sometimes felt that a task was the nurses’ responsibility rather than theirs.
Ineffective delegation had several subthemes. One was failure of the nurse to obtain “buy-in” of the nursing assistant. A second subtheme was delegating without retaining accountability. And the third was lack of conflict management skills. Rather than dealing with these appropriately, many nurses end up doing the tasks themselves, taking away from other activities.
Some nursing staff get in the “habit” of not completing certain aspects of care. Once an aspect of care gets omitted once, particularly if there are no obvious untoward consequences, it tends to get omitted over and over. (Some of you will recall we have referred to this in other columns as “normalization of deviance”). In the subsequent concept paper (Kalisch 2009b) Kalisch and colleagues discuss the influence of the “norms of the team”. An example given is that if nurses perceive that other nurses often do not ambulate patients, new nurses will tend to conform to that practice.
Lastly, denial about care not done was common, particularly for that care delegated to others.
Though they were not included as formal “reasons” in Kalisch’s original paper (Kalisch 2006) there were several other important contributing factors noted. One was that nurses were more likely to complete aspects of care that physicians ordered or asked about frequently. Another was that those aspects where untoward consequences are delayed were more likely to go uncompleted. For example, some of the consequences of inadequate nutrition or ambulation or teaching are not seen until after discharge.
Another study using the MISSCARE survey (Shuckhart 2010) found 3 factors noted in the Kalisch concept paper (Kalisch 2009b) contributed to many of the reasons for missed care. These included labor resources (63.2%), material resources (36.7%), and communication (31.9%).
In a test of the concept Kalisch and colleagues (Kalisch 2012) applied the MISSCARE survey and a measure of nursing staffing (hours per patient day or HPPD) to look at relationship to patient falls in 11 acute care hospitals of varying size. As expected, hours per patient day was negatively associated with occurrence of patient falls and the higher the missed care score the higher the patient fall rates. The study suggested that missed nursing care was at least one of the mediators of the relationship between staffing levels and falls.
The more recent study that brought the formal concept of missed care to our attention (Ausserhofer 2013) found frequent evidence of undone nursing care in almost 500 hospitals in 12 European countries. Results did show that in hospitals with more favorable work environments and better nurse:patient staffing ratios and those with lower proportions of nurses carrying out non-nursing tasks, fewer aspects of care were left undone. The accompanying editorial (Wakefield 2013) raises a number of questions for future research regarding the concept. It also emphasizes a recently recognized concept “complexity compression” as a likely contributing factor to missed nursing care. By that the author means that nurses are often asked to assume additional and unplanned responsibilities while at the same time conducting their other responsibilities in a condensed time frame.
All the articles cited in today’s column have certainly brought the concept of missed care to our attention. Using tools like the MISSCARE survey to identify what aspects of care are not being completed, trending them over time and, most importantly, identifying and ameliorating the root causes could result in significant improvement in patient outcomes.
We also suspect that we could apply similar concepts to care by physicians (eg. in office practices or clinics) or other healthcare workers in other settings and find many of the same factors leading to missed care in those settings.
Kalisch and colleagues have done a superb job in bringing into the open a problem that has long flown under the radar and identified a significant opportunity for improvement.
Ausserhofer D, Zander B, Busse R, et al. on behalf of the RN4CAST consortium. Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Qual Saf 2013; Published Online First: 10 November 2013 doi:10.1136/bmjqs-2013-002318
Wakefield BJ. Facing up to the reality of missed care BMJ Qual Saf 2013; Published Online First: 18 November 2013 doi:10.1136/bmjqs-2013-00248
Kalisch BJ. Missed Nursing Care: A Qualitative Study. Journal of Nursing Care Quality 2006; 21(4): 306–313
Kalisch BJ, Williams RA. Development and Psychometric Testing of a Tool to Measure Missed Nursing Care. J Nurs Admin 2009; 39(5): 211-219
Robert Wood Johnson Foundation (RWJF). INQRI Researcher Patti Hamilton Explores Why the "Weekend Effect" is Putting Patients at Risk. Robert Wood Johnson Foundation. Publications and Research. September 30, 2009
Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. Journal of Advanced Nursing 2009; 65(7): 1509–1517
Shuckhart MC. The MISSCARE Nursing Survey: A Secondary Data Analysis (Thesis). Fort Worth, Texas. University of North Texas Health Science Center 2010
Kalisch BJ, Tschannen D, Lee KH. Missed nursing care, staffing, and patient falls. J Nurs Care Qual 2012; 27: 6–12
Shuckhart MC. The MISSCARE Nursing Survey: A Secondary Data Analysis (Thesis). Fort Worth, Texas. University of North Texas Health Science Center 2010
Print “Missed Care: New Opportunities?”
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
In our May 29, 2012 Patient Safety Tip of the Week “Falls, Fractures, and Fatalities” we briefly mentioned that the inpatient psychiatric/behavioral health unit is one area in which attention to fall risk tends to be less than optimal. Our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry” highlighted the fact that injuries from falls are more likely with falls on psychiatric/behavioral health units.
A “snapshot” of falls in behavioral health hospitals compared to other hospitals published by the Pennsylvania Patient Safety Authority (PPSA 2010) showed patient harm was more likely in falls in behavioral health hospitals (9.6% compared to 3.7% in non-behavioral health hospitals). The VHA National Falls Data Collection Project also demonstrated that overall fall rates were lower on behavioral health units but percentages of falls with injury were higher on those units (Stalhandske 2008).
Many of the same risk factors for falls in any inpatient setting are present in patients on psychiatry/behavioral health units. But there are also some risk factors and contributing factors that are unique to the inpatient psychiatry unit. Compared to med/surg units where patients are largely confined to bed or chairs (even though we encourage early ambulation) patients on behavioral health units are usually much more active. Hence the increased risk for falls may simply be related to this increased opportunity to fall. Scanlan et al. (Scanlan 2012) looked at activity during falls and found that the majority occurred on walking or transferring. Location of falls was most often bedrooms, outdoor areas, corridors and bathrooms. Lee and colleagues (Lee 2012) noted that falls most often occurred as patients were getting up from bed or a chair or wheelchair, walking/running, bathroom-related, or behavior-related.
Lee et al. point out that patients on behavioral health units are on a variety of medications that may increase the fall risk (antipsychotics, antidepressants, sedative/hypnotics, and others). The PPSA study also showed a greater percentage of medications related to falls were reported by behavioral health hospitals than other hospitals (70.3% versus 57.6%).
Some patients may be confused or agitated. Others may have impaired gait or balance, sometimes as a result of extrapyramidal side effects of their medications. Many of the medications cause orthostatic hypotension. The elderly patient on the behavioral health unit is especially at risk for falls with injury. Lee et al. noted that sometimes behavioral health units restrict use of canes or other devices that could assist ambulation because such might also be used as weapons.
Our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry” also discusses the potential roles that sleep disturbances, multiple medical comorbidities, and the primary psychiatric diagnoses may play. And the factors noted in our December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities” apply equally well to psychiatry/behavioral health units as other units. In fact, some of the bathroom assist devices we might use to help prevent falls (eg. grab bars) may be “loopable” items that represent a suicide risk and are not used on psychiatry/behavioral health units.
The VA National Patient Safety Center, which does a great job of aggregating lessons learned from RCA’s across the VA system, put together such lessons learned as they pertain to falls on behavioral health units (Lee 2012). In addition to the predisposing factors noted above, the most common root causes they identified were environmental hazards, poor communication of fall risk, lack of suitable equipment, and a need to improve the system of falls assessment. Assessing the environmental risks, using a checklist, is one of the most important steps in preventing falls and fall-related injuries.
The VA has a long history of successful collaboarative patient safety programs related to falls and fall-related injuries (Stalhandske 2008). These have included the National Falls Collaborative Breakthrough Project, the development and deployment of the National Falls Toolkit, and the National Falls Data Collection Project. The National Fall Collaborative Breakthrough Project involved 40 participating facilities and achieved a remarkable 62 percent reduction from baseline for major injuries. Most of you are probably already familiar with the VA NCPS Falls Toolkit, a compendium of useful references, resources, presentations, posters, and spreadsheets that were culled from existing research and the Falls Collaborative.
VA’s National Falls Data Collection Project grew out of a desire to create an incentive for people to use the Falls Toolkit and to develop some outcome measures for the effectiveness of falls programs. Participating facilities collected and reported various data elements from January 2004 through March 2006. Over the course of the 2 years, there was a reduction in major injuries as a percent of falls in all three unit types. This change was especially apparent in the behavioral health setting, with a relative rate reduction of 64.3 percent.
Despite much research on falls occurring on medical-surgical units and in long-term care settings, falls on inpatient psychiatry units are still relatively understudied. A new VA collaborative project (Quigley 2014) addressed prevention of falls and fall-related injuries on psychiatry/behavioral health units. This VA collaborative project looked at evidence-based interventions for fall prevention and injury prevention and modified the interventions for inpatient psychiatry. For example, grab bars cannot be used on psychiatry units because they may be loopable and, hence, a suicide risk. Similarly, height-adjustable beds with electrical cords would not be allowed on psychiatry units because of the suicide risk.
Ultimately they recommended each of the following across all their participating sites:
Admittedly, the evidence base for hip protectors is mixed but does suggest they are protective for high risk populations. Because the units could not use height-adjustable beds, the use of floor mats to prevent injuries from falls from beds was considered a prime intervention.
Expert faculty provided monthly lectures, coaching, and mentoring through biweekly conference calls and collaborative e-mail exchange.
There was evidence of improvement in several process measures after implementation of the program at the VA collaborative sites. There were small improvements in the fall injury risk assessment and discharge education. Use of hip protectors did not change but was at a relatively high level (55.8% for high risk patients) even before the project began. The biggest improvement, however, was seen for use of floor mats which increased from a baseline of 24.4% to between 36.3% to 49.0% after implementation.
It’s probably too early to determine the impact of this program on injuries related to falls. Their data graphs demonstrate, as expected, some variation in rates from quarter to quarter. While there has probably been an overall downward trend in fall rates, the rates of falls with injury have changed little. The percentage of falls with injury trend is upward but likely because the denominator (overall fall rate) has decreased. The results indicate there is a continued need for programs aimed at reducing injuries from falls.
We hope that you’ll go back to our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry” for many useful tips on fall prevention in behavioral health patients and also to some of our prior columns related to falls listed below:
PPSA. Data Snapshot: Falls Reported by Behavioral Health Hospitals. Pa Patient Saf Advis 2010; 7(4): 149-150
Stalhandske E, Mills P, Quigley P, et al. VHA’s National Falls Collaborative and Prevention Programs. In Henriksen K, Battles JB, Keyes MA, Grady ML (eds.) Advances in Patient Safety: New Directions and Alternative Approaches. Volume 2. Culture and Redesign. AHRQ 2008
Scanlan J, Wheatley J, McIntosh S.. Characteristics of falls in inpatient psychiatric units. Australas Psychiatry 2012; 20(4): 305-308
Lee A, Mills PD, Watts BV. Using root cause analysis to reduce falls with injury in the psychiatric unit. Gen Hosp Psych 2012; 34(3): 304-311
NCPS Falls Toolkit. VA National Center for Patient Safety updated July 18, 2013
Quigley PA, Barnett SD, Bulat T, et al. Reducing Falls and Fall-Related Injuries in Mental Health: A 1-Year Multihospital Falls Collaborative. J Nurs Care Qual 2014; 29(1): 51-59
December 10, 2013
Better Handoffs, Better Results
In the late 1980’s New York State adopted recommendations of the Bell Commission to limit the number of hours housestaff could work in a week. The Bell Commission was convened after the Libby Zion case had highlighted issues related to fatigue and supervision of physicians in training. At the time we actually asked Dr. Bell what the evidence base was that the change in housestaff hours would have a beneficial effect on patient outcomes. His response was that incidents reported in NYS were more frequent on evenings and weekends. We pointed out that those were also the times where cross-coverage occurred most frequently and that important information was often suboptimally transmitted during handoffs. We suspected that benefits from reduced housestaff fatigue might be balanced by detrimental effects of an increased number of handoffs that would occur after the change in housestaff hours.
Subsequently other states and ACGME have adopted significant restrictions in housestaff hours. As you all probably know, the evidence of an impact of restricted housestaff hours on patient outcomes and patient safety has been mixed and contradictory. The most recent study (Sen 2013) found that although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being but has been accompanied by an unanticipated increase in self-reported medical errors.
So, while the new restricted housestaff hours are likely here to stay, we have subsequently focused our attention on improving handoffs and transitions of care and responsibility.
In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available” we highlighted the good work on handoffs done by researchers and clinicians at Boston Children’s Hospital (Starmer 2012, Boston Children’s Hospital 2012). Now a new study from Boston Children’s Hospital (Starmer 2013) found that implementation of a resident handoff bundle was associated with a significant reduction in medical errors and preventable adverse events. There were also improvements in multiple process measures pertaining to handoffs. Importantly, there were no untoward effects on resident workflow and time spent with patients actually increased post-intervention.
The resident handoff bundle included an educational/training component (that included TeamSTEPPS™), standardization of the verbal handoff, and restructuring of the handoff format (eg. team handoffs instead of separate intern-to-intern resident-to-resident handoffs, use of quiet private locations for handoffs, etc.). A printed handoff template that had been in use prior to the intervention continued to be used. However, one unit in the intervention also used a computerized handoff tool that automatically imported a number of data elements from the electronic medical record.
The standardized format used for the verbal handoff used the mnemonic “SIGNOUT?” (Horwitz 2007):
S Sick or DNR (highlight sickest or unstable patients and those that are DNR)
I Identifying data (name, age, gender, diagnosis)
G General hospital course
N New events of day
O Overall health status/clinical condition
U Upcoming possibilities with plan, rationale
T Tasks to complete overnight with plan, rationale
? Any questions
The overall medical error rate improved from 33.8 to 18.3 per 100 admissions after implementation. Preventable adverse events improved from 3.3 to 1.5 per 100 admissions. Nonpreventable adverse events did not change.
Process measures that improved included comprehensiveness of the written handoffs and an increase in verbal handoffs done in quiet, private locations. As you might expect, the unit that also used the computerized handoff tool had fewer key omissions of data on the written handoff documentation. Despite the more frequent use of quiet private locations for handoffs, the mean number of interruptions per handoff session did not change (though the mean number of interruptions per patient did decrease after the intervention).
Time spent on verbal handoffs did not change, and time spent at the computer did not increase. And time spent by residents in bedside patient care actually increased from 8.3% in a 24-hour period to 10.6% after the intervention.
One thing lacking in almost all prior studies on handoffs in healthcare settings has been objective measures of errors and adverse events. Most published studies linking patient outcome improvement to improved handoffs have used subjective measures. The current Starmer study (Starmer 2013) used pre-defined objective measures. It’s really the first study to demonstrate that improved handoffs translate into improved clinical outcomes.
The study did have some limitations, as noted by both the study authors and the author of the accompanying editorial (Horwitz 2013). Perhaps most importantly, the pre-intervention period included the summer and autumn following housestaff change whereas the “after” period was during the subsequent winter, so an experience effect cannot be excluded as a confounding variable. Also, because the intervention was a “bundle” of interventions, it is impossible to determine whether one or more of the individual interventions was more responsible than others for the observed improvements. Also, because the study was done at a single pediatric hospital the generalizability of the findings is unknown.
The accompanying editorial (Horwitz 2013) was written by Leora Horwitz, who was coauthor of the “SIGNOUT?” structured format (Horwitz 2007) and coauthor of previous work demonstrating adverse consequences of poorly done handoffs (Horwitz 2008). She also points out that results of the mutli-instituional I-PASS study (see our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and our June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available”) are expected to be published soon (check the I-PASS Study website for updates).
As we noted in our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” mnemonics and the tools or format that they denote may be very helpful in your handoffs. The key message is that you need to implement tools that address the needs of each particular type of handoff that occurs in your organization. Key to good handoffs is discipline in performing them, doing them in a setting conducive to uninterrupted communication, and ensuring communication is two-way (i.e. that the recipient has adequate opportunity to ask questions and get clarification).
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 Duty Hour Reforms on Interns and Their PatientsA Prospective Longitudinal Cohort Study. JAMA Intern Med. 2013; 173(8): 657-662
Starmer AJ, Spector ND, Srivastava R, et al. and the I-PASS Study Group. I-PASS, a Mnemonic to Standardize Verbal Handoffs. Pediatrics 2012; 129(2): 201 -204
Boston Children’s Hospital. I-PASS: Standardizing patient "handoffs" to reduce medical errors. News Release April 29, 2012
Starmer AJ, Sectish TC, Simon DW, et al. Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA 2013; 310(21): 2262-2270
Horwitz LI, Moin T, Green ML. Development and Implementation of an Oral Sign-out Skills Curriculum. J Gen Intern Med. 2007 October; 22(10): 1470–1474
Horwitz LI. Does Improving Handoffs Reduce Medical Error Rates? JAMA 2013; 310(21): 2255-2256
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of Inadequate Sign-out for Patient Care. Arch Intern Med 2008; 168(16): 1755-1760
I-PASS Study website.
Print “Better Handoffs, Better Results”
December 17, 2013
The Second Victim
Last week we were following the NTSB investigation of the tragic Asiana plane crash in San Francisco this past July. Our regular readers know we often use aviation analogies to help us understand root causes that underlie many of the adverse events we see in healthcare. The current NTSB investigation, of course, is loaded with examples that apply equally to aviation and healthcare, including training issues, learning curves, failure to heed alarms, failure to buck the authority gradient, cultural barriers, automation surprises, safety systems temporarily unavailable while under repair, and many more. At some point we’ll probably do a full review of the NTSB investigation with lessons learned that can be applied to healthcare.
But what caught our attention in this case were the “second victims”. The primary victims in this crash, of course, were the passengers and crew members who were injured or killed. “Second victims” are personnel involved in the errors that lead to adverse outcomes, be they in aviation or in healthcare. In the NTSB case they might be the pilot, copilot, first officer, etc. In healthcare they are most often physicians and nurses and pharmacists. Albert Wu, M.D. is generally recognized as coining the term “second victim” (Wu 2000).
In the Asiana crash we couldn’t help but wonder how the lives of the pilot, copilot, first officer, driver of the rescue vehicle that ran over a victim, and others have been impacted and what support was rendered to them after this terrible accident. In healthcare we still do a suboptimal job of attending to the needs of second victims.
Our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist” linked to a checklist we developed back in the early 1990’s to ensure attention to critical things an organization needs to do after a serious event (Serious Incident Response Checklist). The last item on the checklist, support for caregivers involved, is very important and often overlooked. Caregivers undergo a variety of deep emotions when one of their patients is harmed, particularly when they feel they may have contributed in some way to that adverse outcome. So each organization must have some mechanism for providing needed support and assistance to any physicians, nurses, pharmacists, etc. that may have been directly or indirectly involved in the incident or had been actively involved in the care of the patient.
One of the most important contributions to our understanding of “second victims” came from researchers at the University of Missouri (Scott 2009). Scott and colleagues interviewed 31 second victims (10 physicians, 11 nurses, 10 other) involved in serious events and identified 6 stages that constitute the natural history of second victims. They found that, regardless of the gender or profession or years of experience of the healthcare worker, the second victim phenomenon is a life-altering experience with long-term impact. Both psychological symptoms and physical symptoms were common in second victims. Intensity varied and was often influenced by factors such as the relationship the provider had with the patient or family or the age of the patient being similar to that of a provider’s family member. External stimuli (eg. same location, similar name, similar diagnosis) often triggered thoughts about the incident.
But they found that “second victims” typically went through the following 6 stages:
The first stage is what occurs immediately after the adverse event and consists of trying to realize exactly what happened, often while continuing to care for an unstable patient. The second stage was characterized by “a period of haunted re-enactments”. Feelings of personal inadequacy and periods of self-isolation were common during this period and caregivers often repeatedly asked themselves “what if?”.
The third stage involved seeking support from a trusted individual, often a colleague or supervisor or personal friend or family member. But many could not identify such a trusted individual. During this period they endured doubts about their professional career and worry about whether others would ever trust them again. Particularly critical here was lack of support. Particularly when departmental colleagues or those in supervisory roles were not supportive those feelings of doubt increased. The rumor mill can be especially dangerous. But just as much harm comes from others avoiding the second victim or avoiding talking about the events. (Note that this stage typically occurs before the root cause analysis is done and before all the facts and contributing factors may be known. It is one reason we always recommend the RCA begin as soon as possible after a serious adverse event.)
The fourth stage, enduring the “inquisition” is where the second victim realizes that the organizational response to the events may have repercussions for them. This is where the second victim wonders “will I lose my job?”, “will I lose my license?”, “will I be sued?”, etc.
The fifth stage is seeking emotional support from others (loved ones, coworkers, colleagues, supervisors, or professional support services). But often second victims even had questions about what they could discuss because of legal and regulatory (eg. HIPAA) considerations.
The last stage really is one of 3 paths the second victim might follow. Some “dropped out”, meaning they changed their professional role, moved to a different practice setting, or even left their profession. Others “survived”, meaning they continued to practice at expected levels but continued to be plagued by the event. Yet some “thrived”. Those were the ones who had something positive come out of the experience.
The culture of an organization is extremely important in determining how well second victims are supported. If an organization truly takes a learning approach in their RCA’s and focuses on system factors and avoids the “blame and train” approach, many of the stages of the second victim natural history may be ameliorated. But don’t fail to understand that the culture of an individual department may differ from that of the overall organization. That local departmental culture may trump all attempts by the organization to foster Just Culture.
The root cause analysis (RCA) is also critically important. We’ve already noted that the promptness of the RCA is important in getting out the facts and quelling the “rumor mill”. The goal of the RCA is to identify factors that contributed to the event with the intent of changing them so that future similar events do not occur. It is extremely important that during the RCA we attempt to put ourselves in the position of the players as events unfolded. It’s all too easy for us to have hindsight bias and say or think things like “why didn’t they see that obvious…?”. In almost every RCA we participate in there will be several others who breathe a sigh of relief that they were not put in the same position that the second victims were put in. That recognition often leads to helping provide the sort of organizational and colleague support necessary for helping get a second victim into a desirable “path”.
That, of course, raises the question about who should be involved in the RCA’s. Your RCA should not be about “who?” but rather about “why?”. The questions you should be asking are:
Our feeling is that the people who are involved, no matter what their hierarchical status, can tell you not only where and what the problems are, but also how to fix them. So we feel that those involved in the event should be at the RCA table. But there are pros and cons. On the pro side, you need to know what they were thinking as events evolved. On the con side, you need to avoid empathy for staff involved precluding objective evaluation of facts. Unfortunately, even in this day and age of transparency and adopting the concept of disclosure and apology, we still see some individuals who are unwilling to participate in the RCA. This often comes from the usually misguided perception that anything they might say could be legally “discovered”. We usually point out to such individuals that things they might say during the RCA are much more likely to be mitigating and helpful to them. There are also rare circumstances where an involved party might not be invited to “sit at the table”. Those are cases where there is a clear “hierarchical” problem in the organization and it is likely that other participants or witnesses may be intimidated enough to prevent them from speaking out honestly and completely.
But most important is that the second victim receive feedback in a prompt fashion after the RCA and investigation have taken place. A recent study (Ullstrom 2013) found that many second victims needed to understand and learn from the event. But many of the second victims reported lack of followup after conclusion of the investigation.
Providing support for the second victim has to be better thought out. We’ve evolved over time. We have to admit that when we first added that step to our Serious Incident Response Checklist in the early 1990’s we usually just made sure that the second victim was hooked up with the organization’s EAP (employee assistance program) program. That’s not what we are looking for today! While some second victims may eventually need support from outside or professional counseling, it is the support from colleagues and coworkers that is much more likely to have a positive impact. Virtually all studies done on second victims indicate the need for support from colleagues and supervisors.
Physicians in training may be particularly vulnerable (Wu 1991, Wu 2012) and whether they get support from colleagues and/or mentors or supervisors is critical. Wu and Steckelberg (Wu 2012) note that some organizations, such as Johns Hopkins Hospital and the University of Missouri and the University of Illinois at Chicago, have formal programs for second victims.
There are some tools and resources readily available that may help your organization deal more effectively with “second victims”. MITSS (Medically Induced Trauma Support Services) is a non-profit organization whose mission is to support healing and restore hope to patients, families, and clinicians impacted by medical errors and adverse medical events. Several of the authors noted above are advisors to this organization which has developed very useful toolkits to help both patients/families and clinicians/second victims cope in the aftermath of significant adverse events. MITSS makes available an organizational assessment tool for clinician support, a sample comprehensive workplan for organizations, and a clinician support toolkit. In addition, they have videos from actual second victims that describe how second victims have been able to turn their bad experiences into something positive.
Two literature reviews in recent years (Lewis 2013, Sirriyeh 2010) have noted that, although negative emotional and psychological responses after medical errors are widespread, positive outcomes may occur as well. A lot depends upon the culture of the workplace and the organizational response to the incident. Improved professional relationships following discussion of an error have been reported by physicians. Improved teamwork due to increased assertiveness following such incidents has also been reported.
One thing we have felt has been very beneficial for second victims is the trend to disclosure and apology. You’ll note that in our Serious Incident Response Checklist, which we developed in the early 1990’s, notification of the patient and/or family was deemed essential. We’ve subsequently written numerous columns on disclosure and apology (see the list at the end of today’s column). From personal discussions with many second victims we have found that the net effect on them is that disclosure and apology provides them with a great deal of relief. A study in nurses (Crigger 2007) also emphasized the importance of disclosure and apology in reaching a positive self-reconciliation following mistakes. Our multiple columns on disclosure and apology demonstrate that such is best for all involved, the patients and families, the professionals involved, and the organization. It is one of the key elements in helping all move to closure and something positive coming out of unfortunate events.
Actually, we would really define at least two subtypes of second victims. One type is the person most directly involved with the error that may have been the proximate cause of the adverse event. The other type is the person who knew that something was not right but did not speak up forcefully enough to change the course of events. Both likely suffer from the many negative reactions experienced by all second victims but each may have some unique reactions. Understanding these may be helpful in designing support systems for each of these second victims. The latter type of second victim is less likely to question their clinical abilities or fear licensure actions or loss of employment but still may feel intense guilt. We’ve found that the policy of disclosure and apology has had a positive impact on this type of second victim. In the old era they would live with constant feelings of guilt that no one ever revealed what had happened. Another recent review of the literature on nurses’ experience of medical errors (Lewis 2013) also noted that most nurses feel that patients and family members have a right to be told about medical errors and that failure to disclose increased feelings of distress in the nurses. But many nurses were unclear about their roles in such disclosure.
Another manner of helping the second victims to “move on” is to actually involve them in describing to others what happened to their lives after their adverse event. You have heard us use the phrase “stories, not statistics” many times (see our December 2009 What’s New in the Patient Safety World column “Stories, Not Statistics”). Stories are powerful ways to get the attention of healthcare providers and get them to say “Wow. I bet that could happen here”. Many of those stories are told by the families of primary victims of incidents. However, even more powerful are those stories told by healthcare workers who were the second victims. When you hear their stories you leave thinking “that could easily have been me”. While reliving the events and telling there stories can be very stressful for second victims, it also provides something positive in that they at least know their stories may help prevent future similar primary and second victims.
For example, we’ve seen signs of disinterest in audiences hearing about surgical fires. You can almost hear them thinking “We’ve never had a fire in our OR” or “That’ll never happen there”. But let a surgeon or anesthesiologist or nurse tell them how their lives were impacted after such a fire and that will get their attention! It also brings considerable comfort to the person telling the story knowing that they may be helping to prevent harm to someone else.
In our January 31, 2012 Patient Safety Tip of the Week “Medication Safety in the OR” we noted how anesthesiologists have used the technique of “stories, not statistics” to help prevent errors. We noted a medication safety video from the Anesthesia Patient Safety Foundation (APSF 2012) that includes some clips you may have previously seen in ISMP videos highlighting testimonials from some providers at the “sharp end” of unfortunate medication incidents in the OR. That video and their Spring 2010 Newsletter (APSF 2010) provide real-life examples of errors that led to deaths or other serious outcomes. Most of you are also familiar with the “Beyond Blame” video (available through ISMP online store in the US) and we mentioned above the videos available through MITSS (Medically Induced Trauma Support Services). Using such “stories” or real-life examples, told from the point of “the second victim” (the provider involved), is a very useful way to get buy-in from all parties to address potentially serious problems.
Clearly the “second victim” phenomenon is a very real and serious problem. Many very good people have had their lives devastated by adverse events in which they were involved. Some never fully recover, some leave their profession, yet others recover and make something positive come out of the experience. We all need to do a better job of helping those second victims move toward the latter outcome. That means developing a learning culture for the organization, avoiding a “blame and shame” culture, providing prompt feedback to involved parties when there is an investigation or RCA, providing peer level support for involved parties, and endorsing the disclosure and apology approach to dealing with medical errors, and giving second victims a chance to “tell their story” to others in a constructive manner. Having a formal process for identifying and helping second victims is a must for all healthcare organizations. We also need to look at all levels of our organizations. Sirriyeh et al. (Sirriyeh 2010) note that most of the literature on dealing with medical errors is based on events in hospital settings and very little is known about responses to errors in ambulatory settings. Clearly, we have a big opportunity to learn more about dealing with the “second victim”.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
Other very valuable resources on disclosure and apology:
Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320: 726–727
Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009; 18(5): 325-330
Ullström S, Sachs MA, Hansson J, et al. Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf 2013; Online First 15 November 2013 doi:10.1136/bmjqs-2013-002035
Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA 1991; 265: 2089–94
Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf 2012; 21(4): 267-270
MITSS (Medically Induced Trauma Support Services)
Lewis EJ, Baernholdt M, Hamric AB. Nurses' Experience of Medical Errors: An Integrative Literature Review. Journal of Nursing Care Quality 2013; 28(2): 153-161, April/June 2013
Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. Qual Saf Health Care 2010; 19(6): e43 Published Online First: 31 May 2010
Crigger NJ, Meek VL. Toward a Theory of Self-Reconciliation Following Mistakes in Nursing Practice. Journal of Nursing Scholarship 2007; 39(2): 177–183
APSF (Anesthesia Patient Safety Foundation). Medication Safety In The Operating Room: Time For A New Paradigm (video). 2012
APSF (Anesthesia Patient Safety Foundation). APSF Newsletter. Spring 2010
ISMP. “Beyond Blame” video (available through ISMP online store in the US)
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