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October 6, 2015
Suicide and Other Violent Inpatient Deaths
There has been a lot of attention in the Canadian healthcare system recently about suicide in hospital inpatients. The Toronto Star (Carville 2015) reported a sampling of half of Ontario hospitals found 96 inpatient suicide deaths since 2007 and a further 760 inpatients seriously harmed while attempting suicide. In addition, the Canadian Patient Safety Institute and Health Quality Ontario just published the first list of “never events” for Canadian hospitals (CPSI 2015) and it includes patient suicides or serious harm related to suicide attempts.
And, of course, Canada is not alone. The Joint Commission sentinel event statistics continue to show 80-90 suicides per year reported as sentinel events in the US over the past decade (Joint Commission 2015). While suicides numerically are more common in non-hospital settings, fatal suicide attempts are more common in inpatients than in outpatient or residential settings (NYSOMH 2013).
The Toronto Star article noted that suicides and attempts occurred in all hospital departments, from maternity to neuro-clinical, emergency, medical and psychiatry and that methods ranged from strangulation and suffocation to drowning, overdose and electrocution.
But not all violent deaths of inpatients are suicides. Others violent deaths may occur in patients who are confused or attempting to abscond from the hospital. But many of the root causes and contributing factors are common to both occurrences.
Our first column on preventing inpatient suicides was our January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides”. In that we discussed changes that were made, primarily on behavioral health units, after a New York State report (CQC 1989) and the first Joint Commission Sentinel Event report on inpatient suicides (Joint Commission 1998). Since hangings were the most frequent method of inpatient suicide in the New York State report, attention was directed to environmental factors including exposed pipes, showerheads, bars in showers and toilet stalls. The commission recommended environmental safeguards such as use of breakaway physical structures. Joint Commission also recommended that breakaway hardware actually be tested regularly (weight testing to ensure that hardware will, in fact, break away when sufficient weight is applied). Other environmental safeguards include keeping doors closed, and keeping sharps or other hazardous materials away from patients. The Joint Commission Sentinel Event Alert noted 75% of inpatient suicides were by hanging but also noted that 20% involved jumping from roofs or windows. So careful attention to access to such sites is important.
While the NYS report focused on inpatients in psychiatric facilities, the 1998 Joint Commission Sentinel Event Alert noted that of 27 suicides occurring in general hospitals, 12 occurred in med-surg units and one in the emergency room. In an excellent review, based on root cause analyses (RCA’s) of inpatient suicides and suicide attempts in the VA Hospital system, Mills and colleagues (Mills et al 2008) noted methods of suicide varied by location. Whereas hanging/asphyxiation, cutting, and fires occurred most often on the psychiatric units, overdoses, jumpings, stabbings, and ingestion of chemicals was more common on non-psychiatric units. They provide tables describing the types of anchor points in hangings, the materials used as nooses, the implements used in cuttings, and the locations for jumpings. They point out that, for a variety of reasons, it may be impossible to eliminate the materials used for nooses so they suggest a focus on eliminating anchor points. For example, they note that interior doors and cabinets can be removed or replaced with accordion doors that cannot be used as anchor points. And they recommend that things like door knobs, railings, faucets and hooks be eliminated or constructed so as to break away when weight is applied. They also note that most of the attempted overdoses took place on units other than psychiatric inpatient units (though many of these units were detox units, etc.) so careful assessment of security of medications is important on all units.
In 2010 The Joint Commission issued an update (The Joint Commission 2010) to its previous Sentinel Event Alert on preventing inpatient suicide and focused on suicide occurring outside of psychiatric units (see our December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”). That provided statistics about suicide on various units, places the suicides take place, and means used. They pointed out that there are 2 types of patients who commit suicide on med/surg units: (1) those admitted after a suicide attempt and (2) those with no known psychiatric disorder or known suicide intent. They detail the many risk factors for suicide plus the potential warning signs. Suicide on med/surg units also tends to occur earlier after admission than those occurring on behavioral health units.
They discuss many of the environmental items, usually not available on psychiatric units but readily available on med/surg units, that may be used in suicides. These include items such as bell cords, sheets, restraint belts, various types of tubing, bandages, etc. But key contributing factors are lack of screening, failure to identify risk or recognize warning signs, lack of appropriate training, poor communication, and lack of appropriate staffing for proper observation. They make a number of recommendations regarding screening for depression and suicide risk (both inpatient and emergency department) and watching for behaviors that are potential warning signs of impending suicide attempts. They then offer tips about engaging the patient and family or others capable of providing peer support. And they stress the importance of communication at all levels of care.
A coalition of healthcare organizations has put together a national “Zero Suicide” campaign. That campaign focuses on prevention of suicide in all parts of the healthcare continuum and stresses the important roles of leadership, cultural change, training, communication, and transitioning. But one of the key areas they stress is identification of at-risk patients. Historically, one of the problems has always been identifying those patients who are at risk for suicide. While there are lots of studies noting various risk factors for suicide, there were few validated tools for accurate risk assessment. That is no longer the case. One of the core elements of the Zero Suicide program is use of the Columbia-Suicide Severity Rating Scale (Posner 2011). The C-SSRS may be found online (see also our December 2011 What’s New in the Patient Safety World column “Columbia-Suicide Severity Rating Scale”).
One important consideration, since so many patients at risk for suicide enter the hospital via the emergency department, is that the initial risk assessment should begin in the emergency department (McBroom 2013). But suicide risk must not be considered as an isolated event in time. Suicide risk assessments are often incomplete or not done and the 1998 Joint Commission alert especially noted a dearth of suicide reassessments. Sound familiar? How often have we noted that other key assessments in healthcare, such as fall risk or DVT risk assessment, are done on admission but are not repeated even though clinical circumstances have changed during the hospital course? Another issue is that even though the reason for admission may have been related to a suicide attempt, the patient on admission may be unable to cooperate with a suicide risk assessment (eg. the patient may be comatose or obtunded because of a drug overdose). Sometimes many days pass where the patient physically would have been incapable of another suicide attempt but, ironically, as they begin to improve medically the suicide risk reappears.
Risk assessments should be done not only on admission, discharge, and all transitions of care but also repeated frequently as the clinical course demands. It is also particularly important to consider the risk of suicide in patients on leave or pass and several studies have also noted the association between such leaves and suicide (see our April 2, 2013 Patient Safety Tip of the Week “Absconding from Behavioral Health Services”).
Another critical factor we see over and over is that there may be inadequate training for those charged with close monitoring or observation of patients. This is especially the case on med-surg floors when patients are identified as being at high risk for suicide, other self harm, or wandering and elopement. A case from a year ago illustrates many of the problems encountered with such patients on non-behavioral health units (Darragh 2014). A patient with an “impulse control disorder” following head trauma was on continuous observation by a hospital security guard in an ICU when he entered the bathroom and locked the door. He then smashed double-paned locked windows and jumped to his death from the sixth floor. The guard had not received the same training that nurses who usually provide continuous observation would have had. Such would have required continued observation of the patient in the bathroom at least via a partially open door.
Surprisingly, many completed suicides occur in patients who were on close observation protocols. One study looked at human factors to improve observation practices (Janofsky 2009). Janofsky reviewed the literature on observation practices and did a FMEA (Failure Mode and Effects Analysis) at Johns Hopkins Hospital and found that the language used to describe observation practices and procedures had not been standardized and that the terminology and practice varied widely, even in the same health system and across shifts and units. Moreover, staff often tended not to follow observation policies or covertly modified them and some considered observation a low-level task that was not clinically useful. He noted Hopkins had one level of intermittent observation and 3 levels of continuous observation. In the intermittent level patients are monitored every 15 minutes. In the lower level of continuous observation one staff member may observe more than one patient but the patient must be kept in constant view. At 1:1 observation one staff member must remain in close proximity at all times, with no physical barriers between the patient and observer. But the highest level (“intensive’) requires staff remain within arm’s length of the patient at all times in an adequately lighted area. That includes observation during hygiene and toileting activities. They may use security personnel for protection with patients at high risk of violence but the security personnel do not perform observation.
The FMEA done by Janofsky showed critical failure modes caused by communication failures between physicians, nurses, and observers. Often nurses’ workflow issues interfered with regular communication with observers. Sometimes observers were not comfortable in communicating changes to nursing staff. Shift changes often interfered with communication. And both expectations and documentation requirements for the observers were often inconsistent. After feedback they developed a simple support list for the observers and nurses, and they formalized handoffs. They also found unclear physician and nurse decision making regarding when to start or stop constant observation.
We suspect many other organizations are having similar problems. The role and activities and expectations of the observers are often poorly defined whether the observation is for suicide risk or wandering risk. And without more structure to those there are also obviously difficulties in training observers.
And one other caveat: when we put a patient on 1:1 observation, whether for suicidal risk or because of delirium, we also need to remember it is not practical for any one individual to remain continuously vigilant for long periods of time nor should they be engaged in other activities. Tishler et al (Tishler 2009) recommend changing the observation person every two hours to avoid burnout.
And we’ve discussed some of the tools available to help identify risk factors for inpatient suicide that might be mitigated or avoided. In our January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides” we noted that the VA had developed a mental health environment-of-care checklist (MHEOCC). That checklist is available online on the VA Patient Safety website. And in our July 2012 What’s New in the Patient Safety World column “VA Checklist Reduces Suicide Risk” we discussed a study that demonstrated use of the MHEOCC significantly reduced the risk of inpatient suicide (Watts 2012).
Bathrooms are favored sites for patient suicides for several reasons. One obvious reason is that the patient is usually completely or partially out of sight of any observers. Another reason is that many bathrooms can be locked from the inside. The other is that they typically contain many loopable items. While most behavioral health units have removed locks and loopable items from such bathrooms, that is seldom the case in other areas of the hospital. Many of you will recall our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt” where we challenged you to find a bathroom in your radiology suite or a supply closet on a med-surg unit. Both have numerous implements a suicidal patient could use to commit suicide and may be lockable from the inside. And in most cases the key to open the door from the outside is not readily available, allowing the patient ample time to commit the act.
Another potentially vulnerable situation is one in which an inpatient who is at risk for suicide or wandering (whether on a behavioral health unit or med/surg unit) is transported to another area of the hospital such as the Radiology suite. In our several columns on use of a “Ticket to Ride” checklist for intrahospital transports (see, for example, our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport”) we have emphasized inclusion of an item on the checklist to alert staff of potential suicide. If the patient is at risk, appropriately trained staff would need to accompany the patient and especially ensure he/she is not allowed into a locked bathroom.
Another potential vulnerability has to do with fire alarms. In one case a patient pulled a fire alarm which automatically unlocked doors on a behavioral health unit, allowing him to escape and jump to his death from a rooftop (Pfeiffer 2010). After we heard about that case we began to include inspection of stairwells and rooftop access points adjacent to behavioral health units in our patient safety walkrounds or environmental walkrounds.
While the focus of today’s column has been on prevention of inpatient suicides, it is critical we don’t lose focus on a potentially even more vulnerable period for suicide – the transition period following hospital discharge. Most such suicides occur within the first 72 hours following discharge or within the first 30 days.
Given the nationwide shortage of psychiatrists, getting timely followup arranged can be problematic. The “Zero Suicide” approach, as adopted by NYS Office of Mental Health (NYSOMH 2013), stresses the importance of the “warm handoff” and use of “bridger” staff. The latter are peer specialists who meet with patients either face-to-face or by phone prior to discharge and accompany the patients to their first outpatient appointment. They also ensure that additional appointments are scheduled and educate the patients about other support services.
But what about those patients who reject further treatment at discharge? A “caring letter” expressing concern and support sent to the patient every four months has been shown to reduce the completed suicide rate in a randomized controlled trial (NYSOMH 2013).
So what should your organization be doing to reduce the suicide risk? We recommend you consider the following:
Some of our prior columns on preventing hospital suicides:
See also our previous columns on wandering, eloping, and missing patients:
Carville O, Boyle T. How do suicides happen in hospitals? Toronto Star 2015; Sept. 27, 2015
CPSI (Canadian Patient Safety Institute)/Health Quality Ontario. Never Events for Hospital Care in Canada. September 2015
The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. Sentinel event statistics as of 7/9/2015.
New York State Office of Mental Health. Getting to the Goal. Suicide as a Never Event
in New York State. August 2013
CQC (New York State Commission on Quality of Care). Preventing Inpatient Suicides: An Analysis of 84 Suicides by Hanging in New York State Psychiatric Facilities (1980-1985). 1989
Joint Commission. Sentinel Event Alert Issue #7. Inpatient Suicides: Recommendations for Prevention. November 6, 1998
Mills PD, Watts BV, Miller S, Kemp J, Knox K. DeRosier JM, Bagian JP.
A Checklist to Identify Inpatient Suicide Hazards in Veterans Affairs Hospitals
Joint Commission Journal on Quality and Patient Safety. Volume 36, Number 2, February 2010 pp. 87-93(7)
The Joint Commission. Sentinel Event Alert Issue #46. A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department. Sentinel Event Alert 2010; 46: 1-5 November 17, 2010
Zero Suicide in Heatlh and Behavioral Healthcare. website
Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: Initial Validity and Internal Consistency Findings from Three Multisite Studies With Adolescents and Adults. Am J Psychiatry 2011; 168(12): 1266-1277
Published online November 8, 2011
C-SSRS scales for clinical practice.
McBroom S. Reducing Inpatient Suicide Risk In The Hospital Setting. Compass (McNeary, Inc.) 2013; 12(3): 1-4
Janofsky JS. Reducing Inpatient Suicide Risk: Using Human Factors Analysis to Improve Observation Practices. J Am Acad Psychiatry Law 2009. 37(1): 15-24
Darragh T. State: St. Luke's staff not properly trained to monitor man who jumped to death from hospital window. The Morning Call (Allentown, PA) August 6, 2014
Tishler CL, Reiss NS. Inpatient suicide: preventing a common sentinel event. General Hospital Psychiatry 2009; 31: 103-109
VA. Mental Health Environment of Care Checklist. 2015
Watts BV, Young-Xu Y, Mills PD, et al. Examination of the Effectiveness of the Mental Health Environment of Care Checklist in Reducing Suicide on Inpatient Mental Health Units. Arch Gen Psychiatry. 2012; 69(6): 588-592
Pfeiffer R. Man survives plunge from roof of hospital. Niagara Gazette 2010; October 17, 2010
October 13, 2015
Dilaudid Dangers #3
Actually, we’ve done more than 3 columns on the dangers associated with use of HYDROmorphone (Dilaudid) and usually recommend hospitals avoid including it in standardized order sets and even restrict its use to individuals specifically “privileged” to order it, such as pain management physicians.
But recent research reveals a disturbing trend: HYDROmorphone is increasingly replacing morphine as a first line opioid for pain management in hospital inpatients. A study done using data from the University Health Systems Consortium (UHC) from October 2010 through September 2013 (Gulur 2015) found that over the three year period the use of HYDROmorphone increased 22% and 17% among surgical and medical patients, respectively, while use of morphine decreased 22% and 6% in surgical and medical patients, respectively. During the study period HYDROmorphone actually overtook morphine as the more commonly used analgesic in surgical patients.
In addition, adverse events (defined as use of naloxone on the same day as a dose of opioid) were more frequent in patients receiving HYDROmorphone (1.11% vs. 0.86% in those receiving morphine). While length of stay was almost one day longer in patients receiving morphine, the 30-day readmission rate was 1.37% higher in surgical patients receiving HYDROmorphone and 3.41% higher in medical patients receiving HYDROmorphone.
The study does, however, have significant limitations. First it relied on administrative data that is more intended for billing than clinical uses. The reasons for use of one agent rather than the other could not be determined from the data and the data did not indicate which patients were on PCA pumps. The data also lacked good risk adjustment. And, perhaps most importantly, the only adverse events identified were those requiring rescue with naloxone.
So there are unanswered questions. But these data are in keeping with our own experience with HYDROmorphone and the trend in usage is bothersome. The authors of the study also cite studies showing that common side effects (nausea, vomiting, and pruritis) are no different between the two drugs and that equipotent doses of each drug have no significant difference in efficacy, adverse effect profile or patient preference. One reason clinicians often give for use of HYDROmorphone over morphine is less pruritis with HYDROmorphone but a meta-analysis showed no difference in pruritis between the two drugs (Felden 2011).
Opioid use in the hospital setting is substantial and it’s not just surgical patients who are receiving opioids. Over half (51%) of medical inpatients receive opioids, often in high doses (Herzig 2014). That study also showed hospitals with higher opioid-prescribing rates had higher adjusted relative risk of a severe opioid-related adverse event per patient exposed.
The Commonwealth of Massachusetts Board of Registration in Medicine issued an Advisory regarding the safety of HYDROmorphone in September 2012 (Commonwealth of Massachusetts 2012). They had previously issued such an Advisory in 2007 but issued the new one after receiving 26 reports of complications related to the use of HYDROmorphone since the 2007 Advisory. They noted that half the patients were under 60, most were female, and most events occurred on the night shift. Most had comorbidities or use of concomitant medications that predisposed them to respiratory depression. Events were described with all routes of HYDROmorphone administration. The Advisory provided some case studies and lessons learned and made recommendations, most of which focused on systems improvements and many of which we have previously recommended and are discussed below.
Ironically, problems with Dilaudid may be an unintended consequence of a patient safety initiative taken by most facilities. Demerol (meperidine) was removed from formularies a number of years ago because a toxic metabolite was causing significant untoward effects. Dilaudid became the alternative many physicians chose and most healthcare workers were much less familiar with Dilaudid. Obviously, the trend has continued and, as the Gulur study shows, Dilaudid use has now surpassed morphine use in many hospitals.
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.
A second factor is that HYDROmorphone crosses the blood-brain barrier faster than morphine does, resulting in faster analgesic effect. However, this also means the side effect of respiratory depression would occur earlier as well.
That 2012 Commonwealth of Massachusetts Advisory (Commonwealth of Massachusetts 2012) lessons learned and multiple recommendations. Some hospitals began to require the clinicians who prescribe and administer HYDROmorphone undergo a privileging process and annual competencies to verify proficiency with pain management and opioid reversal. Others discourage the use of HYDROmorphone as a first line narcotic analgesic and require consultation/approval of Anesthesia/Pain Management or Pharmacy. Many created standard order sets and eliminated use of ranges for dosing or timing. Some limited hospital stock to 1 mg/ml vials and floor access was eliminated or tightly controlled. Several eliminated the override function from automated dispensing cabinets for HYDROmorphone. They also describe the education process for physicians, nurses and patients and their families. Monitoring of patient prescribed HYDROmorphone was discussed and special attention was given to patients sent to areas like Radiology after receiving HYDROmorphone.
To reiterate from our multiple columns on Dilaudid dangers, here are strategies you should consider to reduce the risk of Dilaudid/HYDROmorphone (and other opioid) adverse events:
Yes, we use “Dilaudid Dangers” as a catchy title. But it’s no laughing matter. Use of HYDROmorphine has become a real risk lurking in most hospitals and other healthcare settings today despite warnings from multiple patient safety organizations and the trend toward its increased use is bothersome.
Our prior columns on patient safety issues related to Dilaudid/HYDROmorphone:
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
Gulur P, Banh E, Koury K, et al. Morphine versus hydromorphone: does choice of opioid influence outcomes? 40th Annual Regional Anesthesiology and Acute Pain Medicine Meeting May 14-16, 2015 Las Vegas, Nevada
Felden L, Walter, C, Harder S, et al. Comparative clinical effects of hydromorphone and morphine: a meta-analysis. Br J Anaesth 2011; 107(3): 319-328
Herzig SJ, Rothberg MB, Cheung M, et al. Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals. J Hosp Med 2014; 9(2): 73-81
Commonwealth of Massachusetts Board of Registration in Medicine. Quality and Patient Safety Division. Review of Safety and Quality Reviews Involving Hydromorphone. September 2012
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
Print “Dilaudid Dangers #3”
October 20, 2015
Updated Beers List
The American Geriatrics Society has updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (AGS 2015). Whereas the original 1991 version of Beers Criteria was largely based on expert consensus, the last two updates have attempted to make them more evidence-based. There are actually now two lists, one for most older adults and a second for older adults with specific conditions. The new criteria also include considerations for drug-drug interactions and dosing issues related to impaired renal function.
The release also comes with a companion article on how to use the updated Beers criteria (Steinman 2015). It helps clinicians understand that the criteria are not absolute (i.e. that a drug listed as potentially inappropriate may still be appropriate for some patients) and that flexibility is needed. The medications are listed in tables along with the recommendation, rationale, quality of evidence, and strength of recommendation.
Also, for the first time, they’ve released a list of suggested alternative medications for drugs appearing on the Beers list (Hanlon 2015). This is much needed since all too often busy clinicians simply prescribe a drug on Beers list because they don’t have the time to research alternative agents to use.
One of the principles put forth is that optimal application of the AGS 2015 Beers Criteria involves identifying potentially inappropriate medications and, where appropriate, offering safer nonpharmacological and pharmacological therapies. For example, the updated criteria recommend avoiding antipsychotics for behavioral problems unless behavior modification has failed or the patient is considered a physical threat to self or others.
There have been some significant changes from the last update. Of note the nonbenzodiazepine, benzodiazepine receptor agonist hypnotics (eszopiclone, zaleplon, zolpidem) are to be avoided without consideration of duration of use because of their association with harms balanced with their minimal efficacy in treating insomnia. Also added is the avoidance of the use of proton-pump inhibitors beyond 8 weeks without justification.
Another important principle is that payers and managed care organizations should not use Beers criteria in a punitive fashion or use excessive restrictions (such as prior authorization) on use of these medications in individual cases. But it does discuss how Beers criteria might be incorporated into CPOE or electronic prescribing systems and how tracking trends and patterns of Beers medications might be used to provide useful feedback to clinicians.
The AGS 2015 Beers Criteria also acknowledge that they are complementary to other explicit criteria used to assess medication appropriateness, such as the Screening Tool of Older Persons’potentially inappropriate Prescriptions (STOPP) criteria and the Screening Tool to Alert doctors to the Right Treatment (START) criteria (see our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?”).
The “how to use” article (Steinman 2015) also has good recommendations on how to discuss Beers criteria medications with patients and other physicians.
It also provides a warning that many Beers medications should not be stopped abruptly. A good rule of thumb is that a drug dose is usually safe to taper down at the same rate that it can safely be tapered up. We’ve discussed “deprescribing” in detail in several prior columns (March 4, 2014 “Evidence-Based Prescribing and Deprescribing in the Elderly”, September 30, 2014 “More on Deprescribing”, May 2015 “Hospitalization: Missed Opportunity to Deprescribe” and July 2015 “Tools for Deprescribing”).
The “alternatives” article (Hanlon 2015) lists drugs by class along with suggested alternative medications and references. For example, under chronic kidney disease it lists all nonaspirin nonsteroidal anti-inflammatory drugs and suggests as potential alternative drugs acetaminophen, SNRI, topical capsaicin, or lidocaine patch with links to appropriate reference articles for these. The article also provides discussion and reference to non-pharmacologic alternatives, where appropriate for various conditions, such as transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS), cognitive behavioral therapy (CBT), acupuncture, management of delirium or dementia-related behaviors, management of urinary incontinence, and sleep hygiene. This article is an excellent and much needed addition to the tools available to treating clinicians.
A timely article in JAMA Internal Medicine’s “Teachable Moment” series just happens to discuss a case of a patient with dementia who goes downhill after a fall with vertebral compression fracture (Larson 2015). The geriatrician doing a home hospice visit on the patient suspected polypharmacy, deprescribed several drugs, instituted several non-pharmacological interventions and educated family about how to respond to the patient, and then used some of the alternative medications you’d find in the Hanlon article. The patient dramatically improved following these measures.
And just a reminder – drugs appearing on Beers list may not be the ones most responsible for patient visits to the emergency department or hospitalizations. 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. In our November 12, 2013 Patient Safety Tip of the Week “More on Inappropriate Meds in the Elderly” we noted a study from Australia (Miller 2013) that 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.
And, lastly, a recent article showed that the medications most likely to harm the elderly are…
…antibiotics!!! At least for patients in primary care in New Zealand. Not the drug category we’d have suspected. We would have predicted opiates, anticoagulants, or diabetes drugs as the most likely offenders. But a new study from New Zealand found medications to be the number one cause of harm to ambulatory patients age 65 and older and antibiotics the most common offenders (Wallis 2015). There is actually only one anti-infective drug on the most recent Beers list.
All the latter studies don’t mean we should downgrade the importance of Beers criteria. The new updated Beers criteria and the 2 companion articles are extremely valuable tools that can be used wisely in clinical decision making and help protect our patients. We find the article on alternative medications (Hanlon 2015) to be an especially useful addition that may make it easier for clinicians to move patients from potentially inappropriate drugs to safer drugs or non-pharmacological interventions.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
American Geriatrics Society. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriat Soc 2015; Article first published online 8 Oct 2015
Steinman MA, Beizer JL, DuBeau CE, et al. How to Use the American Geriatrics Society 2015 Beers Criteria - A Guide for Patients, Clinicians, Health Systems, and Payors. J Amer Geriat Soc 2015; Article first published online 8 Oct 2015
Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. J Amer Geriat Soc 2015; Article first published online 8 Oct 2015
Larson CK, Kao H. Hospice Diagnosis: PolypharmacyA Teachable Moment
JAMA Intern Med 2015; Published online September 28, 2015. doi:10.1001/jamainternmed.2015.5253
Wallis KA. Learning From No-Fault Treatment Injury Claims to Improve the Safety of Older Patients. Ann Fam Med 2015; 13(5): 472-474
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
Wallis KA. Learning From No-Fault Treatment Injury Claims to Improve the Safety of Older Patients. Ann Fam Med 2015; 13(5): 472-474
Print “Updated Beers List”
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
The Joint Commission (TJC) recently published its latest Sentinel Event Alert “Preventing falls and fall-related injuries in health care facilities” (The Joint Commission 2015). The new alert notes that every year hundreds of thousands (!!!) of patients fall in US hospitals and 30-50% of those falls result in injuries. Falls with serious injury have consistently been in The Joint Commission’s Top 10 sentinel events and 63% of those have resulted in death. The alert notes that a fall with injury adds 6.3 days and $14,000 cost on average to each hospital stay.
The most common contributing factors identified by TJC from sentinel event reports are:
So it’s no surprise that TJC recommendations focus heavily on addressing those common deficiencies. The alert identifies a variety of tools and resources that have been amassed on fall prevention (with links to those resources). The alert highly recommends use of a standardized assessment tool to identify fall and injury risk factors but also to assess an individual’s risks that may not have been captured through the tool. Interventions, then, should be tailored to the individual patient’s identified risks.
In our October 2015 What's New in the Patient Safety World column “Patient Perception of Fall Risk” we noted the Joint Commission Center for Transforming Healthcare now has a Targeted Solutions Tool for Preventing Falls. The 7 hospitals participating in that project were able to reduce the rate of patient falls by 35 percent and the rate of patients injured in a fall by 62 percent. Extrapolated to a typical 200-bed hospital the number of patients injured by falls could be reduced from 117 to 45 annually and almost $1 million in cost reduction.
The sentinel event alert stresses the importance of leadership adopting fall prevention as a priority. It recommends having an executive sponsor for fall prevention programs, empowered to ensure accountability, build support, and ensure adequate people and fiscal resources for such programs. But it also stresses the importance of having a clinical champion who can influence stakeholders. An interdisciplinary falls prevention team is a key element in any successful fall prevention program and there needs to be a focus on communication issues, such as handoffs.
The alert then delves into a topic dear to our heart – what to do after a fall has occurred. That should include not only proper assessment of the patient but also a post-fall huddle held as soon as possible following the fall. At the latter the team should address why the patient fell, whether appropriate interventions were in place, how the care plan will change, and what can be done to prevent future similar occurrences. But it also stresses continued reassessment of the patient, looking for changes in the patient’s condition that might, for example, suggest a subdural hematoma (see our own prior columns on minor head trauma in anticoagulated patients listed at the end of today’s column).
For postfall assessment they provide links to two tools in the AHRQ Falls Toolkit: the “Postfall Assessment, Clinical Review” and the “Postfall Assessment for Root Cause Analysis”. The latter tool is one of the few we’ve seen that stresses the importance of checking orthostatic vital signs postfall. We’ve seen cases over and over where the history was strongly suggestive of orthostatic hypotension but no one ever bothered to check orthostatic signs at the most important time – right after the fall (see one of our typical rants on this in our April 16, 2007 Patient Safety Tip of the Week “Falls With Injury”).
The sentinel event alert ends with links to great fall prevention resources from organizations like the AHRQ, IHI, ECRI Institute, ICSI, The Joint Commission Center for Transforming Healthcare, and the VA Center for Patient Safety.
At the same time a slightly different view on fall prevention comes from the UK. Much of the fall prevention recommendations for both clinical and organizational approach to falls come from two guidances from the National Institute for Health and Care Excellence (NICE 2013, NICE 2015). Results of an audit of hospital falls were recently released in the UK (Royal College of Physicians 2015). They often found a disparity between policies and practices. For example, only a fifth of patients were able to access their call bell and a third could not safely access their walking aid (if they used one). In addition, only 16% had their orthostatic vital signs assessed.
The UK takes an interesting approach to falls in the hospital. It has specifically recommends that hospitals cease using fall risk prediction tools. Instead they recommend that all adults aged 65 and older (and those aged 50-64 who are judged by a clinician to be at higher risk of falling because of an underlying condition) be considered at risk for falls. In our August 4, 2009 Patient Safety Tip of the Week “Faulty Fall Risk Assessments?” we discussed some of the ideas that went into the recommendation not to use fall risk prediction tools. Most notably, they argue that low scores may give you a false sense of security that a patient is not likely to fall. Such “scores” also tend to promote general fall prevention interventions rather than ones specifically tailored to the individual patient.
The UK also has a different (more liberal) approach to bed rails than we do on this side of the ocean (see our December 18, 2007 Patient Safety Tip of the Week “Bed Rails”). Because a systematic review of the scientific literature had indicated that falls from beds with bedrails “are usually associated with lower rates of injury” the UK recommendation has been that hospitals have policies on bedrail use and audit such use for appropriateness. The current audit showed all hospitals had policies but only half audited their use.
Recommendations made following the UK audit:
Each hospital should also have a falls steering group and a multidisciplinary falls working group that work in collaboration.
Another very interesting risk factor for falls, not routinely appearing on current fall risk assessment tools, was revealed at the recent ID Week 2015 conference. A study from the Massachusetts General Hospital (MGH) showed a surprising relationship between patients coming to the ER because of a fall and being diagnosed with an infection (Manian 2015). They reviewed 161 patients who had fallen and were subsequently diagnosed with an infection. The infection was not initially suspected in 41%. Most had none or only one of the usual signs of infection. For example, only about 20% had fever. Importantly, the morbidity and mortality associated with these patients was substantial. 18% suffered a fracture related to the fall (20% for those age 65 and older) compared to a national average of 2%. And 18% of those with infection died in hospital, compared with national rates of 3-5% for those over 65 admitted to a hospital because of a fall.
Several potential explanations for falls in those with infection were mentioned. The most obvious is that fever and perhaps anorexia might lead to dehydration and orthostatic hypotension. Another is that UTI’s (which accounted for 44% of the MGH series cases) may lead to the patient getting up at night, in the dark, to go to the bathroom, a scenario we know as common to falling (see our December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities”). Another possibility might be an infection leading to increased confusion in an older patient with dementia.
In that December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities” we noted that almost half of falls in the hospital occur during activities related in some way to toileting. Anticipating patients’ toileting needs is a critical component of successful hourly rounding programs (see our July 26, 2011 Patient Safety Tip of the Week “Hourly Rounding”). Assisting patients to the toilet late in the evening is particularly important. But perhaps the toileting needs of our patients are better met by aides or staff other than nursing. Perhaps a specially-trained aide or team could work from 10 PM to midnight or 9 PM to 11 PM and just focus on ensuring all patients at high risk for falls get appropriate assistance toileting before they go to sleep. Keep in mind that such attention to toileting is also important in the patient at risk for delirium.
While we concur that fall prevention strategies aimed at the entire hospital population have a role (eg. proper lighting, proper footwear, non-slip and non-trip surfaces, etc.), it is critical that fall risk factors are identified for each individual patient and interventions specific to those risk factors are implemented (see our August 4, 2009 Patient Safety Tip of the Week “Faulty Fall Risk Assessments?”).
Focus should be on potentially modifiable risk factors. But even some seemingly “non-modifiable” fall risk factors may still lead to specific interventions. For example, male gender has been identified in some tools as a risk factor for falls. While you obviously cannot modify that risk factor, you might look extra carefully at toileting needs of the male patient. We don’t know how much of the male risk for falls is “macho” vs. “modesty”. But if that latter is a factor in raising the fall risk during toileting in males, you may need to consider having non-female staff assist the males in toileting activities.
So we don’t think you should ignore non-modifiable risk factors but we think there are some good lessons learned here. While general patient safety efforts are important, focus especially on those things you can modify for the individual patient. So if you are using a fall risk prediction tool, don’t focus so much on the “score”. Rather focus on those specific items in the tool that are modifiable risk factors in individual patients regardless of the overall risk “score”.
Perhaps the most important take-home point from both the Joint Commission and the Royal College of Physicians publications is that policies and education/training are not enough. What’s important is that we make sure our actual practices are in keeping with those policies and best practices. Doing an audit periodically is a good way of assessing if we’re practicing what we preach.
Some of our prior columns related to falls:
Some of our previous columns on falls after correction of vision:
June 2010 “Seeing Clearly a Common Sense Intervention”
June 2014 “New Glasses and Fall Risk”
August 2014 “Cataract Surgery and Falls”
Some of our previous columns on head trauma in the anticoagulated patient:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert. 55: 1-5 September 28, 2015
Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool for Preventing Falls.
AHRQ (Agency for Healthcare Research and Quality). Preventing Falls in Hospitals. A Toolkit for Improving Quality of Care. AHRQ (Rockville, MD) January 2013
“Postfall Assessment for Root Cause Analysis”
“Postfall Assessment, Clinical Review”
NICE (National Institute for Health and Care Excellence). Falls in older people: assessing risk and prevention. NICE guidelines [CG161] Published date: June 2013
NICE (National Institute for Health and Care Excellence). Falls in older people: assessment after a fall and preventing further falls. NICE quality standard [QS86]. Published date: March 2015
Royal College of Physicians (UK). The Falls and Fragility Fracture Audit Programme (FFFAP) 2015. National audit of inpatient falls. Audit report 2015
Manian FA, et al. IDWeek 2015 (Poster #813) as reported by Rosenthal M. Tripped Up by a Bug Instead of a Rug. IDSE (Infectious Disease Special Edition) 2015; 19: October 2015
November 3, 2015
Medication Errors in the OR - Part 2
In our March 24, 2009 Patient Safety Tip of the Week “Medication Errors in the OR” we discussed the many reasons that medication errors are likely to occur in the OR. But, frankly, at that time we were surprised at the paucity of literature on the issue. We had no accurate quantification of how often medication errors occur in that setting. Though the OR was not one of the top 10 sites for medication errors in the USP MEDMARX® database, one study highlighted the serious nature of the outcomes of such errors in the OR (Beyea 2003).
But the big news last week was a new study from the MGH (Massachusetts General Hospital) demonstrating that medication errors in the perioperative setting are extremely common (Nanji 2015). In fact, one in every 20 perioperative medication administrations resulted in a medication error or adverse drug event. The overall rate of 5.3% is pretty close to the rates we typically see on inpatient units. And almost half of all surgery cases had at least one medication error or adverse drug event.
The study utilized direct observation of 277 randomly selected operations plus further chart review of the same cases. 124 of the 277 cases had at least one medication error or adverse drug event. In all, there were 193 events in 3675 medication administrations (153 medication errors and 91 adverse drug events). A third of the medication errors led to adverse events. Moreover, 79% were felt to be potentially preventable. Over half of the events occurred within 20 minutes of the induction period.
The most common error types were labeling errors (24.2%), wrong dose errors (22.9%), and omitted medication/failure to act (17.6%). Three drugs (propofol, phenylephrine, and fentanyl) were associated with 45% of the events.
Patient characteristics had little influence on rates of medication errors or adverse drug events. Longer procedures were associated with more errors and ADE’s, as were procedures in which 13 or more medication administrations occurred. Importantly, the error rates were almost equal between attending anesthesiologists, CRNA’s, and residents.
Perhaps the most striking observation was that the installed barcoding medication safety system was not always utilized. In some cases the barcoding system was not installed in that particular location but in others anesthesia personnel used workarounds to avoid using the barcoding system. In the latter, sticker labels were applied manually to syringes. That actually should not be surprising since we saw multiple workarounds when barcoding was initially introduced to other parts of hospitals (see our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent”).
The Nanji study does far more than simply provide an estimate of how often such perioperative medication errors occur. It provides lots of potential opportunities to reduce such errors, utilizing both technology-based strategies and process-based strategies (see below).
As noted in the accompanying editorial (Orser 2015) this high frequency of errors and ADE’s occurred despite the fact that the MGH uses a barcoding system in the OR and has an electronic documentation system in the OR. The editorialists attribute the high rate of errors and events to observation by independent observers compared to self-reported errors in prior studies.
In our March 24, 2009 Patient Safety Tip of the Week “Medication Errors in the OR” we noted many of the factors that make medication errors in the OR both more likely and more serious when they do occur:
So it should not be surprising that serious outcomes may arise from medication errors occurring in the OR.
Several other organizations have been at the forefront in addressing perioperative medication errors: ISMP Canada, ISMP (US), AORN, and the APSF (Anesthesia Patient Safety Foundation).
Many of you are undoubtedly already familiar with APSF’s video on medication safety in the operating room (APSF 2012). It is based on a consensus conference convened by APSF in 2010 (Eichhorn 2010) and also highlights a patient safety initiative at Wake Forest University Baptist Medical Center (Vanderveen 2010).
The video noted that medication errors occurred in one of every 133 anesthetic administrations (? a gross underestimate in view of the recent findings in the MGH study). The most frequent medications involved included NMBA’s (neuromuscular blocking agents), opioids, benzodiazepines, heparin, epinephrine, antibiotics, and insulin. It also noted that 4% of closed claims in a large anesthesia malpractice database were related to medication errors. 24% of these were “substitution” errors (and NMBA’s and epinephrine were most frequently involved), 18% were “insertion” errors (where a medication never intended for the patient was given inadvertently), and 31% were “incorrect dose” errors. About 50% of the errors led to serious adverse effects for the patient. Contributing factors identified included lack of standardization, no protocols, production pressures, and lack of agreement on best practices. A study of perioperative medication errors from Australia noted about 50% syringe and drug preparation errors (with NMBA’s and opioids again heading the list). 62% were felt to be preventable and contributing factors identified included haste, fatigue, communication difficulties, inattention, and labeling issues.
The video goes on to note several of the features we noted above (from our March 24, 2009 Patient Safety Tip of the Week “Medication Errors in the OR”) that make the OR especially vulnerable to medication errors. In the OR the anesthesiologist is typically the individual who chooses the drug, prepares it, and administers it without the system of checks and balances from nursing and pharmacy that we’d typically see elsewhere in the hospital. In addition, the drugs being dealt with are often high-risk medications and are used in high volume. LASA (look-alike sound-alike) issues are also especially frequent in the OR.
Basic medication safety principles outlined in the video include:
But APSF says these are not enough and therefore advocates a new paradigm for medication safety in the OR, with the acronym “STPC”:
Standardization includes not only drug dosages, dosing units, concentrations, and drug preparation methods but also workplace design. Technology includes better drug identification and delivery systems with technologies such as bar coding systems. The “P” includes provision of dedicated pharmacy resources for the OR and using premixed solutions or prefilled syringes in the OR so the anesthesia personnel are relieved of such preparation activities. The cultural changes needed are adoption of a non-punitive “just culture” type system that encourages reporting of errors and discussion of lessons learned from errors. The culture of “identify, blame, and punish” needs to be replaced by one of accountability.
The “STPC” paradigm suggests that high-alert medications (such as epinephrine and phenylephrine) should be available only in standardized concentrations and be prepared by pharmacy personnel wherever possible. They should be in ready-to-use syringes or infusion form for both adult and pediatric patients. The video discusses the labeling elements needed to meet The Joint Commission requirements (drug name including TALLman lettering where appropriate, concentration in dose per mL, diluent, preparer, preparation date and time, expiration date, standardized colorcoding where available, and barcode). Technology includes systems to identify every medication during preparation and before administration (such as barcoding) and automated systems for documentation and clinical decision support. Such automation of documentation of time a drug is administered also is a time saver that enables the anesthesia personnel to attend to other responsibilities. The most important element under the “P” is for the anesthesia personnel to discontinue routine preparation of medications at the point of care, instead using prefilled syringes or premixed solutions prepared by pharmacists or commercial vendors. The other key element of the “P” is involvement of pharmacists, either directly in a satellite pharmacy in the OR suite or otherwise as part of the perioperative team. They also recommend use of standardized prepared medication kits by case type wherever possible. The “C” is for cultural change including a “just culture” for reporting errors, including near misses, and learning from such reports.
The example of “STPC” provided by the Wake Forest project involved hospital-wide standardization of infusion pump technology, drug libraries, concentrations, dosing units, and dosage limits (Vanderveen 2010). Pump types no longer had to be changed when patients were moved between OR, ICU or med-surg units. Certain “anesthesia only” medications were identified and a list of medications pharmacy would prepare for use in the OR was developed. A strong culture of cooperation and dedication to patient safety and involvement of staff from multiple departments were key to the implementation.
The recent MGH study (Nanji 2015) suggests a variety of both technology-based and process-based interventions. The technology-based ones include use of barcoding systems and clinical decision support tools. Process-based interventions include changing the timing of documentation and reducing the opportunity for workarounds. The latter might include making it slightly harder for anesthesia personnel to get manual stickers in lieu of using the barcode scanner. They also note that being able to connect infusions to the most proximal IV port (ideally through a dedicated carrier line) may minimize inadvertent boluses of IV infusates.
In our March 24, 2009 Patient Safety Tip of the Week “Medication Errors in the OR” we mentioned the an Operating Room Medication Safety Checklist© developed by ISMP Canada in collaboration with the Canadian Anesthesiologists’ Society, the Operating Room Nurses Association of Canada, and ISMP (US) and other parties. The Association of periOperative Registered Nurses (AORN) also produces the AORN Safe Medication Administration Tool Kit, another valuable tool in developing your OR medication safety program.
The current APSF Newsletter also has a timely reminder about an issue related to medications and the OR. It has to do with medication safety issues during emergency transfer of obstetric patients to the OR (Kacmar 2015). It notes that during such emergency transfers there may be inadvertent administration of some of the high-risk medications a patient may have had infusing prior to the transfer. See the article for details and recommendations about which ones to discontinue prior to transport and other issues.
The recent MGH study highlights the significant frequency of perioperative medication errors. Now is a good time for hospitals or free-standing surgery centers to review their medication safety as it applies to the OR and perioperative settings.
Beyea SC, Hicks RW, Becker SC. Medication Errors in the OR - A Secondary Analysis of Medmarx. AORN Journal 2003; 77: 122-134
Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology 2015; October 2015 Newly Published on 10 2015
Orser BA, U D, Cohen MR. Perioperative Medication Errors: Building Safer Systems. Anesthesiology 2015; October 2015 Newly Published on 10 2015
APSF (Anesthesia Patient Safety Foundation). Medication Safety in the Operating Room: Time for a New Paradigm. January 2012
Eichhorn JH. APSF Hosts Medication Safety Conference. Consensus Group Defines Challenges and Opportunities for Improved Practice. APSF Newsletter 2010; 25(1): 1-8 Spring 2010
Vanderveen T, Graver S, Noped J, et al. Successful Implementation of the New Paradigm for Medication Safety: Standardization, Technology, Pharmacy, and Culture (STPC). APSF Newsletter 2010; 25(2): 26-28 Summer 2010
ISMP Canada. Operating Room Medication Safety Checklist©
AORN Safe Medication Administration Tool Kit
Kacmar RM, Mhyre JM. Obstetric Anesthesia Patient Safety: Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery. APSF Newsletter 2015; 30(2): 24-25, 42-43 October 2015
November 10, 2015
Weighing in on Double-Booked Surgery
A recently published Boston Globe investigative report (Abelson 2015) on double-booked surgery at the MGH (Massachusetts General Hospital) has raised serious concerns about the practice of attending surgeons in academic medical centers having two surgical cases ongoing simultaneously. Though the report is as much about hospital politics and power struggles and the manner in which we educate and train our next generation of surgeons, it exposes a controversial patient safety issue.
First, a disclosure is in order. Having done my neurology residency at the MGH, I have the greatest respect for the tradition, history, and outstanding clinical and educational work done at the MGH. And the MGH does good patient safety work. In fact, two of our last 4 Patient Safety Tips of the Week (the one on the trend toward increased use of Dilaudid and the one on medication errors in the OR) were based upon research coming out of the MGH. Perhaps if the Globe report were about another hospital we might come down even harder on the controversial practice. But we will try to maintain our objectivity in the discussion that follows.
The practice, also known as concomitant surgery or overlapping surgery, typically but not exclusively occurs in teaching hospitals. When it occurs in non-teaching hospitals it would be where a physician assistant, specifically credentialed and privileged by the hospital, is delegated to perform specific portions of a surgical procedure. Policies on such require the attending surgeon to be present during the critical portion of the surgery in each of the two cases.
The report cites famed cardiac surgeon Michael DeBakey as the epitome of a surgeon moving from OR to OR doing key parts of surgery on multiple patients. It notes that other specialties, particularly orthopedics, looked at such a model as being very efficient and adopted key components of it.
The Globe report highlights the cases of several patients who had adverse outcomes from their surgery who were unaware at the time that their attending surgeons had been “double-booked”. In fact, the most important theme running through the report is that most patients are unaware that their attending surgeon might not be present during their entire surgery and may be doing surgery on another patient at the same time.
The report goes on to detail how the MGH addressed (or failed to address) complaints about the safety of concomitant surgery that were raised by several anesthesiologists, residents, and a prominent orthopedic surgeon. The latter became a pariah and was criticized for his “crusade” against the practice and was eventually terminated from the MGH after providing redacted medical records to the media.
The MGH has responded with a fact sheet and multiple posts on its website. It notes that it has done a review of concomitant surgery cases done in calendar year 2014 and found that the rate of complications was no higher than for cases of single (non-overlapping) surgery. Moreover, it did revise its policy and procedure on concomitant surgery in 2012 and notes that the new policy has served as a model for other academic medical centers.
We’ve been sticklers when it comes to accountability of the surgeon for the entire course in the OR. In the early 1990’s, we had a case in which a surgeon phoned the OR and told the anesthesiologist to go ahead and begin induction because he would be there shortly, only to cancel the case because a vital imaging study was not available. The patient thus unnecessarily underwent what some might consider the riskiest part of any surgery (i.e. the anesthesia). Fortunately, no harm came to the patient. But we instituted a policy after that requiring surgeons to sign a statement in the patient chart to the effect “I am physically present in the OR and have all the materials I need to proceed” before any patient would undergo anesthesia. Yes, there was some grumbling from surgeons but it’s hard to argue against common sense. A few years later, after a case in which intraocular lenses were transposed between patients, we established one of the earliest protocols for the timeout and identification of patient, procedure, laterality, etc. It served as a model when New York State first developed its “timeout” protocol and that served as a model for ultimate development of Universal Protocol by The Joint Commission.
Below are several of the concerns we have about concomitant surgery from a patient safety perspective:
The Gray Zone
Definition of “the critical portion of the surgery” is the gray zone in both the MGH policy and the CMS policy (described later). The MGH puts the onus on department heads to come up with definitions for each of a variety of surgical procedures. But if I’m a patient with a retained surgical item, the critical portion of the surgery may have been the closing “count” and wound closure, for which my surgical attending may not have been “required” to be present.
Yes, there are times during surgery that complications, emergencies, and unexpected circumstances are more likely to occur. Yet anyone who has spent any time in OR’s or analyzing perioperative adverse events will attest to the fact that those occurrences may pop up at the most unexpected times.
Absent from the MGH policy on concomitant surgery are comments about the surgical timeout process. While it is likely these might be included in a different policy, like their timeout or Universal Protocol policy, there should be specific reference to the timeout process in this policy. The attending surgeon should be an active participant in the initial timeout in every case he/she is responsible for. Moreover, when the attending surgeon switches from one case to another there must be an additional timeout, just like there must always be additional timeouts when other surgeons may come in for part of a case or when there is any other change in medical personnel. This should apply even when the attending surgeon was an active participant in the original timeout because events may have occurred in the interim during his/her absence.
If the attending surgeon leaves one OR prior to completion of the case he/she is obviously not going to participate in the post-op debriefing. Thus, in at least half the double-booked cases the key individual (attending surgeon) is not part of the debriefing. We consider the debriefing to be a very important patient safety tool (see list of our prior columns on debriefings listed at the end of today’s column).
In debriefings you are basically asking “What went well?”, “What didn’t go well?” and “What could we do better next time?”. You’ll often identify the need to fix broken equipment or ensure the availability of appropriate backup instruments. Sometimes it’s something simple like tray set-ups or equipment set-ups that interfered with the surgeon’s movements during the procedure. And you need to be sure that someone follows up on issues identified and communicates back to the group when they are fixed. Also, make sure you identify at the debriefing any problems you had with team communication during the procedure.
Absence of the attending surgeon from such debriefings (or lack of presence of that surgeon from substantial portions of the entire surgery) obviously is a missed opportunity to improve future care.
The debriefing is also an opportunity for the attending surgeon to discuss issues with the resident or fellow who may have been a major participant or even the primary surgeon in the case.
Duration of surgery
The Boston Globe report cited anesthesiologists complaining that patients often had to wait, while still under anesthesia, for considerable periods while their attending surgeon was elsewhere. The Globe cites an e-mail noting that such waits for the attending surgeon while the patient is under anesthesia may sometimes be as long as 2 hours.
We’ve done several columns discussing the complications that may occur as the duration of a surgical procedure increases (see list of our prior columns on surgical duration listed at the end of today’s column). Our March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” discussed time unawareness during many surgeries. In addition to the potential impact on infectious complications, we noted that there are other potential patient safety issues related to prolonged surgical duration such as DVT, decubiti, hypothermia, fluid/electrolyte shifts, pulmonary complications, nerve compression, compartment syndromes, and rhabdomyolysis. Long-duration cases also increase the likelihood of personnel changes that increase the chance of retained foreign objects or retained surgical items (see our August 19, 2014 Patient Safety Tip of the Week “Some More Lessons Learned on Retained Surgical Items”). And the fatigue factor comes into play with longer cases, increasing the likelihood of a variety of other errors.
But the biggest risk is for surgical site infections. Surgical case duration is one of the few modifiable risk factors for surgical infections. A number of studies in the past have demonstrated an association between perioperative infection and the duration of the surgical procedure. In our January 2010 What’s New in the Patient Safety World column “Operative Duration and Infection” we noted a study (Proctor et al 2010) which found the infectious complication rate increased by 2.5% per half hour and hospital length of stay (LOS) also increased geometrically by 6% per half hour.
So any case where the procedure is put on hold while waiting for a surgical attending is putting the patient at unnecessary risk for a variety of complications.
We physicians often take pride in our ability to multitask. Such pride is probably misplaced. Any human activity that requires attention to two different scenarios is prone to error. Some will argue that the two surgeries involved are typically quite similar in nature. That actually makes it much more likely that details from one case may be transposed to the other case. For example, in orthopedic surgery it might be very easy to mistakenly call for an implant of a specific size (or other characteristic) that was appropriate for the “other” patient but not this patient.
The MGH policy mentions nothing about the expected infection control standards for concurrent surgeries. We would anticipate that any surgeon leaving an OR must remove gloves, gown, masks and any other protective gear, then perform appropriate hand hygiene and don entirely new gear before entering the next OR. Knowing habits of surgeons (and others) in multiple OR environments, we are willing to bet that workarounds are common and shortcuts taken.
The role of CMS
If we were doing a root cause analysis, we’d eventually drill down to the role played by CMS (Centers for Medicare and Medicaid Services). In 2006 CMS revised its guidance on billing by physicians in teaching hospitals (CMS 2006). In that document it does discuss when a teaching surgeon may bill for “overlapping” surgeries: “In order to bill Medicare for two overlapping surgeries, the teaching surgeon must be present during the critical or key portions of both operations. Therefore, the critical or key portions may not take place at the same time. When all of the key portions of the initial procedure have been completed, the teaching surgeon may begin to become involved in a second procedure. The teaching surgeon must personally document in the medical record that he/she was physically present during the critical or key portion(s) of both procedures.”
But this is a billing document. Proponents of concomitant surgery often point to this document as CMS endorsing a standard of care. Whether it was actually endorsing a standard of care or not, it clearly set the stage for the issue of money entering into the equation. It basically set the stage for pitting monetary issues against safety issues.
The educational/training mandate
This summer a surgical “perspective” in the Annals of Surgery (Beasley 2015) defended the practice in the name of training: “The incremental acquisition of surgical competence during training is critically important to maintaining a surgical workforce.” No one can argue with that statement. However, incremental delegation of procedures to residents and fellows and provision of incremental responsibility should not require that the attending surgeon be absent from the room.
The Beasley perspective notes the dearth of objective assessment of the efficacy and safety of concomitant surgery. The MGH’s internal review of its concomitant surgery cases can hardly be considered independent and it has not undergone the scrutiny that would be required by a peer-reviewed journal.
The real truth
When you hear the rationale that concomitant surgery improves efficiency and “gives more patients access to our expert surgeons” it belies the real truth: it’s all about the money. The Beasley perspective even implies that maximizing the skills of the attending surgeon and improving efficiency might be a great way to achieve national goals of delivering cost-effective care. Really? In their defense, they do admit that the practice of concomitant surgery needs further study. But shouldn’t we be doing a prospective assessment to see if such practice is safe rather than retrospectively trying to show that it’s not safe?
The ethical issue
And then there is the ethical issue (which is really the most important issue). The biggest revelation in the Boston Globe report was that the patient was usually unaware that their attending surgeon might not be present for their entire surgery. It’s one thing to tell a patient during informed consent that residents and fellows and others will be involved in their surgery and may perform substantial portions of the surgery. But failure to tell them that their attending surgeon may be in a totally different room doing surgery on another patient is a huge ethical breach. Quite frankly, no patient in their right mind should agree to have a major surgical procedure knowing that the attending surgeon, in whom they have placed their trust, will not be in the OR for the duration of their surgery.
The MGH probably happened to be in the wrong place at the wrong time. This report probably could have been done at dozens of academic hospitals across the country. It is a practice that has become frightingly too abundant. We’d like to see a moratorium on the practice until a well-designed prospective study can tell us that the practice is effective, efficient and, most importantly, safe for patients.
We would not personally agree to have surgery with an attending surgeon who might be leaving our procedure to perform surgery on a different patient in a different room. And we don’t know many well informed patients who would. The Boston Globe Spotlight Team has done us all a service in revealing this “dirty little secret”.
Update: See also our November 29, 2016 Patient Safety Tip of the Week “Doubling Down on Double-Booked Surgery”
See our prior columns on huddles, briefings, and debriefings:
Our prior columns focusing on surgical case duration:
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Clash in the Name of Care. Boston Globe October 26, 2015
MGH (Massachusetts General Hospital). What is Concurrent/Overlapping Surgery? Fact Sheet.
MGH (Massachusetts General Hospital). Monitoring Outcomes for Procedural Overlap Surgeries at the MGH. 2014
MGH (Massachusetts General Hospital). Clinical Policy and Procedures. Perioperative Policy for Concurrent Surgical Staffing of Two Rooms. 10/29/2012
Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the American College of Surgeons 2010; 210: 60-65
CMS (Centers for Medicare and Medicaid Services). CMS Manual System. Pub 100-04 Medicare Claims Processing.Transmittal 811. SUBJECT: Teaching Physician Services. January 13, 2006
Beasley GM, Pappas TN, Kirk AD. Procedure Delegation by Attending Surgeons Performing Concurrent Operations in Academic Medical Centers: Balancing Safety and Efficiency. Annals of Surgery 2015; 261(6): 1044-1045
November 17, 2015
Patient Perspectives on Communication of Test Results
Test results missing from patient charts are not uncommon in primary care offices. One study showed lab results were missing in 6.1% of all office visits and radiology reports were missing in 3.8% of all office visits (Smith 2005). In our July 2009 What’s New in the Patient Safety World column “Failure to Inform Patients of Clinically Significant Outpatient Test Results” we noted another study which found apparent failure to inform patients of such abnormal test results 7.1% of the time (Casalino 2009).
There are probably over 30 steps involved between the decision to order a test and communicating the results to the patient and taking actions based upon the results (see our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error”). Even if the chance of error at each step was only about 1%, the cumulative risk of an error is substantial (perhaps as high as 25%). And while many such errors may have little or no adverse impact on patients, the failure to follow up on abnormal lab or radiology tests can have devastating results to patients.
Two studies by Litchfield and colleagues recently highlighted significant gaps in both identifying missing test results and in communicating test results to patients in the UK. In the first (Litchfield 2015a) a phone survey of primary care practices was used. The authors found that the default method for communicating normal test results to patients was having the patient call the practice in 80% of practices and 40% of practices required the patient to call for abnormal test results. 36% of the practices had a physician call the patient if the test result was sensitive or serious. In 18% of practices administrative staff would contact the patient and ask them to book an appointment. When asked if the practice had a system for knowing if a blood test result had been returned, 84% had no such system. 10% assigned a staff member to check paper records of tests ordered against electronic records and 6% thought that their EMR system would highlight missing test results. Significantly, none of the practices had assigned a specific team member the task of recording whether abnormal test results had been returned to the patients. These results in the UK apparently occurred despite the capability of the existing EMR systems in the majority of practices to track test results.
The Litchfield paper provides a nice diagram of all the steps involved in the blood testing process from ordering to return to and acknowledgement by the responsible physician, including all the steps at the laboratory. It identifies steps at which delays or failures are likely to occur. These included spoiled, damaged, or otherwise non-viable samples, misidentified samples, samples with unreadable labels, lost samples, etc. (See also the list of our previous columns on “lab” errors at the end of today’s column.) The Litchfield paper also describes when and how the lab would convey that information back to practices.
In the companion study, Litchfield and colleagues (Litchfield 2015b) did focus groups with both patients and staff to better understand where errors or delays in the process might occur. This is where they constructed a process map and service blueprint in a LEAN-like process that identified potential points of delay and potential failure points. It’s of interest that most of these points impacted patients much more so than practices. They ultimately identified 6 areas where improvements could be made:
The delay in getting an appointment with the phlebotomist was not only frustrating for patients but also led to many simply not getting their blood drawn at all. Physicians and staff noted that often they would only recognize that no results were available once the patient called to get results. Putting the onus on patients to call the office for test results led to telephone gridlock that angered both patients and staff. Requiring patients to call for normal test results led to a huge volume of phone calls. Physicians and staffs were not in favor of calls for normal test results but patients were most interested in receiving them. Patients also were generally unhappy getting their results from untrained office staff who could no answer clinical questions. Patients actually seemed to be interested in the idea that text messaging could be used as a means to communicate results. Staff, however, were concerned about that, noting that patients’ cell phone numbers might change.
Lastly, despite the fact that the clinical management (IT) systems at the practices had the capability of tracking tests results, few practices used this capability or were interested in training their staffs on such use.
In a commentary regarding 2 papers from the UK which showed continued problems in ensuring patients were appropriately notified of abnormal test results Kwan and Cram (Kwan 2015) note the increasing trend of putting test results directly in the hands of patients. They note that HIT regulations and meaningful use criteria require patients have more access to their electronic health records and that patient portals are now a feature of most electronic medical records. They also note that patient interest in portals is greater than physician interest in them. They do outline some of the issues of directly reporting test results to patients, including whether to report only normal or abnormal results or both, how to assist patients in interpreting results, and levels of patient anxiety that may be produced by results.
In another commentary on the 2 Litchfield studies Nancy Elder, who has written extensively on the problem of following up on test results in primary care, talks about team dynamics in achieving quality and safety outcomes (Elder 2015). She notes that in primary care the testing process is often carried out in steps by individuals who are often unaware of the steps before and after their contribution. Elder notes that all too often primary care physicians rely on untrained staff to communicate results to patients. They also often rely on patients to let them know when results are missing. She notes that PCP’s often underappreciate the problem because actual cases of patient harm are relatively rare and they are often “overloaded” responding to minimally abnormal test results of no clinical significance.
So patients are very interested in seeing their test results, whether they are normal or abnormal. But the mode preferred by patients for receiving such results has received little attention.
Now a new study surveyed patients in the US on their preferences for receiving reports of test results (LaRocque 2015). Importantly, in the survey they asked questions about results of specific types of test. The survey assessed comfort with 7 delivery methods: fax, personal voicemail, home voicemail, personal E-mail, letter, mobile phone text message, and password-protected website. The also assessed preferences for receiving information on cholesterol levels, colonoscopy results, tests for non-HIV sexually transmitted infections, and 3 genetic tests.
Not surprisingly, receiving results by fax was the least comfortable for results of all test types. (Note that we caution against hospitals or offices even using fax for sending test result reports to physicians. We’ve seen cases where a physician office fax number changed and a patient report was faxed to a local supermarket! Fax is simply not a secure method for transmission of personal health information and could land you in a heap of trouble for HIPAA violations.)
Home voicemail was also not a preferred method for most people responding to the survey (and, again, we caution you about the potential HIPAA implications of leaving PHI on a voicemail or messaging machine that might be easily accessed by parties other than the intended one). Mobile phone text messaging was also not a popular method for receiving test results. On the other hand, over 60% of respondents were comfortable with receiving results of cholesterol tests and colonoscopy results via personal voicemail, though less than 50% found this method acceptable for STI or genetic test results. Similar results were found for use of personal e-mail and password-protected websites. Password-protected websites were the only method in which >50% of respondents were comfortable receiving STI results and no method was acceptable by >50% for receiving genetic test results.
Interestingly, age was not a factor regarding technology as personal e-mail and password-protected websites were not affected by age. Age was a factor regarding a very old technology: the letter. 71% of respondents age 55 and older would be comfortable receiving a letter with results of the common tests (cholesterol level or colonoscopy results) compared to only 35% for those aged 18 to 24.
Overall, the method with which the largest portion of respondents was comfortable was the password-protected website. The authors note other research has shown patients who have access to patient portals prefer this method over phone calls.
The LaRocque study also shows how comfort levels with technology have probably increased over time. In our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks” we noted a study (Leekha 2009) that looked at patient preferences for notification of test results and noted disparities between those preferences and how they were actually notified. A majority wanted notification via phone call from the physician or nurse practitioner but in reality the majority received notification either via a phone call from a nurse or by a return visit to the office. Use of more hi-tech methods (e-mail, automated answering mechanisms, etc.) were not highly regarded methods, though the average age of the population studied being 70 years may somewhat limit the generalizability of these conclusions. The authors discuss how misalignment of incentives can be a root cause for dissatisfaction (eg. patients dislike having to spend time and money for a followup office visit, whereas providers only get reimbursed for such visits and do not get reimbursed for phone calls).
Undoubtedly a big factor is the patient’s comfort level with technology. Though almost all young people have grown up with technology and use it daily, many of our older patients are not comfortable using computers, smartphones, and other technology tools. (But don’t paint all older patients with one brush! We know lots of our older patients who spend lots of time on computers and are very comfortable with modern technology.)
Any acceptable system for tracking followup on patient tests needs to do the following:
You’d think that today’s sophisticated EMR’s would have built in even better systems for tracking test results. But one big problem is still lack of interoperability among various systems. Many reports still arrive back at the office in paper format rather than an electronic format. Of course, we can scan those paper reports into most EMR’s. Don’t forget: paper-based reports always were vulnerable to the issue of two pages sticking together, often resulting in a report being filed in the chart of the wrong patient.
Also, all the above fail to mention the other huge vulnerability – those tests that the primary care physician did not order but were ordered by others. That is especially a problem with test results done during a hospitalization where a hospitalist or specialist, rather than the PCP, attended to the patient. We discussed those in our Patient Safety Tips of the Week for March 1, 2011 “Tests Pending at Discharge” and August 21, 2012 “More on Missed Followup of Tests in Hospital. That transition of care necessitates that responsibility for follow up needs to transferred and the new responsible physician (the PCP in most cases) needs to know what test results are pending at the time of discharge.
Many physicians, ourselves included, do use patients themselves as a backup check on test results. We tell them “if you have not heard back from us about these tests within x days, call us”. But even then you’d be surprised how many patients never make that phone call. If not given specific instructions regarding communication of test results, the patient should always ask the physician “When should I expect the result to be available?” and then contact the physician if they have not heard those results within a reasonable period of time. The patient should never assume that the test results were normal if they have not heard from the physician or other provider.
Yes, patients are logical partners in the process and they have the most to lose when the process is flawed. But we agree with Nancy Elder that putting the burden solely on patients is problematic. The perfect system for test results management has not yet been designed. But doing the sort of process used by Litchfield and colleagues, which is sort of a combination of LEAN and FMEA, to identify vulnerabilities in your current practices can be very rewarding. Just the significant reduction in unnecessary phone calls you’d expect after implementing a new process should offset the time and effort expended to do such a study. And make sure you include not only every member of your staff in that endeavor but also the most important people – your patients.
See also our other columns on communicating significant results:
Some of our other columns on errors related to laboratory studies:
Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA 2005; 293(5): 565-571
Casalino LP, Dunham D, Chin MH et al. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Arch Intern Med 2009; 169(12): 1123-1129
Litchfield I, Bentham L, Lilford R, et al. Test result communication in primary care: a survey of current practice. BMJ Qual Saf 2015; 24(11): 691-699 Published Online First: 4 August 2015
Litchfield I, Bentham L, Hill A, et al. Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives. BMJ Qual Saf 2015; 24(11): 681-690 Published Online First: 6 August 2015
Kwan JL, Cram P. Do not assume that no news is good news: test result management and communication in primary care. BMJ Qual Saf 2015; 24(11): 664-666 Published Online First: 18 August 2015
Elder NC. Laboratory testing in general practice: a patient safety blind spot. BMJ Qual Saf 2015; 24(11): 667-670 Published Online First: 18 August 2015
LaRocque JR, Davis CL, Tan TP, et al. Patient Preferences for Receiving Reports ofTest Results. J Am Board Fam Med 2015; 28: 759-766
Leekha S, Thomas KG, Chaudhry R, Thomas MR. Patient Preferences for and Satisfaction with Methods of Communicating Test Results in a Primary Care Practice. The Joint Commission Journal on Quality and Patient Safety 2009; 35(10): 497-501
November 24, 2015
Door Opening and Foot Traffic in the OR
We’ve done several previous columns that have discussed the potential negative impact of increased OR foot traffic.
In some of our prior articles on the relationship between surgical duration and SSI rates (see our March 10, 2010 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” and our January 2010 What’s New in the Patient Safety World column “Operative Duration and Infection”), we have noted that OR traffic typically increases in longer duration cases. That likely increases the risk of bacterial transmission as well. As cases go on longer, foot traffic in and out of the OR increases, both as staff go on breaks or change shifts and as interruptions for questions, etc. begin to affect the surgeons and anesthesiologists. Long duration of surgery has long been known to be a factor associated with increased risk of surgical site infection and increased foot traffic may be one factor that increases the likelihood of surgical site infections (Lynch 2009).
Then in our March 17, 2015 Patient Safety Tip of the Week “Distractions in the OR” we discussed a study on distractions in the OR (Wheelock 2015). Not surprisingly, distractions occurred in 98% of cases. They occurred at a rate of 10.94 distractions per case or one distraction every 10 minutes. The most frequent types of distraction were those initiated by external staff entering the operating room. The researchers note that such distractions were unnecessary in 81% of cases! While those researchers actually attributed less significance to their major outcome variables (like teamwork, stress, etc.), they do acknowledge the potential impact on surgical infection rates, which they did not monitor. In several Patient Safety Tips of the Week (“HAI’s: Looking in All the Wrong Places”, “Prolonged Surgical Duration and Time Awareness”, “Operative Duration and Infection”) we’ve noted the risk of infection increases each time the OR door is opened and foot traffic in and out of the OR increases.
Now a new study from Johns Hopkins has formally studied how often OR doors are opened during joint arthroplasty surgeries and the impact on OR air flow (Mears 2015). The researchers measured how often and for how long OR doors were opened during 191 hip and knee arthroplasty procedures. They also measured air pressures in the OR and adjacent corridors. They found that, on average, OR doors were open 9.5 minutes per case and the average time between door openings was 2.5 minutes. As you’d expect the number and duration of door openings correlated with the length of surgery. In 77 of the 191 cases positive pressure within the OR was defeated.
The implications are obvious. While they found only one surgical infection in the 191 cases, the effects of the door opening on OR pressure and air flow theoretically would predispose to surgical infections. OR’s have positive pressure to avoid flow of air and airborne pathogens from nonsterile adjacent areas.
Unfortunately, the Hopkins study did not assess the reasons for frequent door opening (the study was done in a manner that the OR staff was unaware such observations were being made). But if we extrapolate from the Wheelock study (Wheelock 2015) we’d expect a large percentage of the door openings may be from external staff and that most of these may not be necessary.
Mears and colleagues in the Hopkins study note that such frequent door openings are often a sign of OR inefficiencies pertaining to equipment, logistics, and personnel management. They note that the Lynch study correlated the number of door openings with the number of people in the OR. Mears et al. did not record that number. However, we would suspect that number may well be higher in teaching institutions than in community hospitals.
The next step would be to find out the reasons for such frequent OR door openings. Based on those results, possible interventions could be planned and piloted. In our March 17, 2015 Patient Safety Tip of the Week “Distractions in the OR” we noted that, anecdotally, simply having everyone attempting to enter the OR fill out a log entry with the reason for entering substantially reduces the number of people entering.
We agree with Mears et al. that proper planning for surgery and ensuring that all equipment and supplies that will be needed for the procedures are available in the OR is very important. In that regard, appropriate use of pre-op huddles/briefings and post-op debriefings are useful in reducing equipment issues.
The impact of such excessive foot traffic in and out of the OR and the impact of door opening on air flow into the OR is likely of importance from an infection control perspective. But the distractions and interruptions associated with such traffic are likely to have an adverse impact on other efficiencies in the OR. Door openings are probably a good proxy for OR inefficiencies and OR distractions and would be an easily measured parameter that might find use in multiple quality improvement projects.
Note that we have often recommended organizations use video recordings of OR cases that are then reviewed in a constructive manner to assess how will the OR team communicates and works together. While we’ve never looked at OR door openings during such reviews, that would be another valuable opportunity to determine reasons for door openings. Note also that those centers which have implemented RFID (or similar) tracking systems should be able to determine what personnel and equipment are moving in and out of the OR during cases and use that to get a better idea of the reasons for such movement.
Mears and colleagues have done a good job of raising awareness of a potential patient safety vulnerability that needs further research. Our bet is that looking at those vulnerabilities will also provide organizations with opportunities to improve their efficiencies – a win win situation.
Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52
Wheelock A, Suliman A, Wharton RBM, et al. The Impact of Operating Room Distractions on Stress, Workload, and Teamwork. Annals of Surgery 2015; published ahead of print January 23, 2015
Mears SC, Blanding R, Belkoff SM. Door Opening Affects Operating Room Pressure During Joint Arthroplasty. Orthopedics 2015; 38(11): e991-e994
December 1, 2015
Does It Work?
We’ve long been fans of TALLman lettering to help avoid look-alike sound-alike (LASA) drug errors. We’ve recommended its use (eg. HYDROmorphone) in our numerous columns on the dangers of Dilaudid. In fact, we’ve even sometimes suggested our own TALLman lettering schemes for certain LASA drug pairs (see our prior columns “Ophthalmology: Blue Dye Mixup” and “Another Blue Dye Eye Mixup”).
But does TALLman lettering actually reduce such errors? It is a very simple and logical concept so it makes a lot of sense to use. But, like any other patient safety intervention, we should assess whether it indeed reduces errors and does not introduce unintended consequences.
We were quite surprised when we read in a recent safety bulletin on TALLman lettering from ISMP Canada that there were no published studies demonstrating the effectiveness of TALLman lettering in reducing errors associated with drug name confusion (ISMP Canada 2015). Then about a week later came along a study in pediatric hospitals that showed the introduction of TALLman lettering was not associated with any reduction in potential LASA errors (Zhong 2015).
ISMP Canada, recognizing that overuse of this technique might reduce its effectiveness, recommends that use of TALLman lettering be restricted to drug name pairs associated with significant risk to patient safety (ISMP Canada 2015). Therefore, they embarked on a project that began with analyses of reported incidents from several Canadian databases and did a systematic risk assessment to determine which LASA pairs would benefit most from TALLman lettering. They then sought feedback and ultimately published a list of 33 LASA drug pairs. That list is considerably shorter than the 2011 list published by ISMP US (ISMP 2011).
The pediatric study (Zhong 2015) used pharmacy data for pediatric inpatients from 42 children's hospitals from 2004-2012. The researchers searched within each hospitalization for the occurrence of patterns for a total of 12 LASA drug pairs deemed highly relevant to pediatric inpatients. TALLman lettering was implemented in 2007. They performed segmented regression analyses to look for changes after the implementation. They found no downward trend in potential LASA drug error rates over any time period 2004 onwards. They conclude that whether TALLman lettering is effective in clinical practice warrants further study.
One issue that arises in discussions on TALLman lettering is whether we overuse it and create a “fatigue” similar to alert fatigue or alarm fatigue. That is one of the reasons the recent ISMP Canada list (ISMP Canada 2015) was kept so short.
ISMP (US) and other organizations put together TALLman lettering lists after seeking input from multiple stakeholders. An ISMP survey in 2008 showed that most hospitals were using TALLman lettering in some capacity and the majority felt that it was effective in reducing errors (Grissinger 2012). But those responses were largely subjective and anecdotal.
Experimental results in 2008 and early 2009, just as TALLman lettering was being more widely adopted, showed that TALLman lettering reduced drug name confusion errors in a series of laboratory-based tasks, in both younger and older adults, and healthcare practitioners (Filik 2010).
But even one of the studies used to endorse the implementation of TALLman lettering (Gerrett 2009) was somewhat cautious in its recommendations. It noted that, given the results of their lab experiments, the authors would advocate a pragmatic approach with the implementation of a specific rule-based Tall Man variant for a limited and specified set of look-alike, sound-alike medicines. They felt that this was unlikely to result in any greater harm when compared with the then current standard of lowercase or uppercase.
They noted the finding that error in practice was more likely to occur with dose (LASA errors are more likely to occur when the dose of the two drugs, in mg, is similar), formulation or a combination of these with look-alike medicine name highlights the need for broader research.
So does this mean we should stop using TALLman lettering conventions for high-risk LASA drug pairs? Hardly. But it does tell us that we need to do further research in adult populations to determine which TALLman conventions for which drugs are effective in actually reducing LASA errors. Remember, there are other methods that have been used to try to help us distinguish unique letters in drug names (different color letters, different color backgrounds, italics, underlining, different fonts, etc.). But those methods also have largely escaped systematic review for their effectiveness. Also unanswered is whether use of TALLman lettering is equally effective at the dispensing, preparation, or prescribing phases. Use of TALLman lettering probably does not result in harm. However, we also are unaware of any studies that have addressed unintended consequences of either TALLman lettering or any of the other methods. We’ll bet some are out there. Particularly for hospitals with long lists of LASA pairs you might find a TALLman convention for one pair might include a TALL sequence similar to yet another drug.
There have been so many patient safety initiatives that are so attractive in concept yet prove to be ineffective when we get around to actually measuring their impact. Let’s hope TALLman lettering does not fall into that category. But the Zhong study certainly suggests that we need to do a systematic review of the impact of TALLman lettering in multiple other venues.
While waiting for such future studies, it is probably wisest to reserve your TALLman lettering conventions for those LASA drug pairs with the most potential to have serious patient safety consequences in your organizations.
Update: See our July 2016 What's New in the Patient Safety World column “ISMP Updates TALLman Lettering List”.
ISMP Canada. Application of TALLman Lettering for Selected High-Alert Drugs in Canada. ISMP Canada Safety Bulletin 2015; 15(10): 1-3 October 30, 2015
Zhong W, Feinstein JA, Patel NS, et al. Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years. BMJ Qual Saf 2015; published online first November 3, 2015
ISMP. FDA and ISMP Lists of Look-Alike Drug Name Sets with Recommended Tall Man Letters. 2011
Grissinger M. Tall Man Letters Are Gaining Wide Acceptance. P&T® 2012; 37(3): 132-134
Filik R, Price J, Darker I, et al. The influence of tall man lettering on drug name confusion: a laboratory-based investigation in the UK using younger and older adults and healthcare practitioners. Drug Saf 2010; 33(8): 677-687
Gerrett D, Gale AG, Darker IT, et al. Tall man lettering: final report of the use of tall man lettering to minimise selection errors of medicine names in computer prescribing and dispensing systems. Loughborough (UK): National Health Service, NHS Connecting for Health; 2009 http://webarchive.nationalarchives.gov.uk/20130502102046/http://www.connectingforhealth.nhs.uk/systemsandservices/eprescribing/refdocs/tallman.pdf
Print “TALLman Lettering: Does It Work?”
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
In our September 2015 What's New in the Patient Safety World column “Stroke: Doing Less Well Than You Think?” we noted an issue related to the dosing of tPA in acute stroke. That related to the timing of the initial dose and beginning of infusion of tPA and what to do if there is an interruption in the infusion.
But another issue related to the tPA dose is the weight of the patient. Often, in the urgency to administer thrombolytic therapy in a timely fashion, staff do not formally weigh the patient on a scale. They either ask the patient how much they weigh or they estimate the patient’s weight themselves. It turns out that estimating a patient’s weight frequently results in erroneous weights being used in the dose calculation (Barrow 2015). Clinicians underestimated mean difference weight by 1.13 kg between estimated and actual weight but disparities were most likely at the upper and lower extremes of weight. So some patients will be underdosed, others overdosed. Though 80% of patients received a tPA dose within the acceptable range, 11.5% were underdose and 8.1% overdosed.
When they looked at improvement in NIHSS scores, those patients who received a dose in the acceptable range had the greatest improvement. But those in the “underdosed” range (corresponding to the heaviest patients) had less improvement than those in the “overdosed” range. That heavier, underdosed population accounted for about a third of all their stroke patients.
The authors conclude that beds capable of weighing patients should be mandated in emergency rooms for patients with acute stroke.
Of course, errors related to inaccurate weights are not unique to tPA or other thrombolytic therapies. They may occur with any medication that is dosed based upon patient weight. The impact of inaccurate estimations of patient weight on anticoagulation with low molecular weight heparins (LMWH’s) has been discussed several times (NPSA 2010; dos Reis Macedo 2011). In the latter study of enoxaparin dosing in an ED population, it was found that when weight estimation was used to determine the enoxaparin dosage 25% of the patients were inadequately anticoagulated during the initial crucial phase of treatment.
In our August 2, 2011 Patient Safety Tip of the Week “Hazards of e-Prescribing” we highlighted several studies and examples of erroneous doses due to confusion about patient weights. ISMP Canada reported a case in which a chemotherapy agent was given in excessive dosage after the height and weight on a computerized order entry system were transposed (ISMP Canada 2010). They discussed several factors that contributed to the problem and had several excellent suggestions on ways to avoid this type of error. ISMP (US) reprinted this in August 2010 (ISMP 2010). ISMP and ECRI had co-authored an article on the importance of accurate patient weights in a 2009 PPSA Safety Advisory. That article mentioned several cases in which weights were incorrectly entered into computerized systems, confusing pounds with kilograms, resulting in overdosing or underdosing. The PPSA article notes that the weight issue is so important because most of the drugs that have weight-based dosing are hi-alert drugs.
Patient self-reported weights appear to correlate better with actual weights. Finardi and colleagues found a negligible small mean difference between self-reported and measured weights in high risk elderly ED patients (Finardi 2012). Neither old age nor acute disease status impaired the strong correlation of reported and measured weight. Therefore, those authors conclude that self-reported weight can be used as approximation for real body weight in elderly ED patients presenting with non-specific complaints.
In the setting of acute stroke a patient may be unable to communicate what they weigh. When we discuss patient safety with our patients or laypersons we tell them they should record their weight (and keep it up-to-date) on their list of medications that they should keep with them at all possible times. Tools like the Patient Med List from the Massachusetts Coalition for the Prevention of Medical Errors include a place at the top of the list for patients to record their weight and height.
And don’t forget the other setting where inaccurate weights become problematic – the patient who has been hospitalized for a long time. We’ve seen some patients who have been hospitalized for several weeks, typically with multiple complications, who have lost considerable amounts of weight. Unfortunately, clinicians often use the weight recorded on admission (or “locked” into a field in the EMR that is used for weight-based calculations) to calculate a medication dose rather than using the current weight. This can often lead to overdosing of such patients.
The key lesson: always use the actual current weight if you are doing a weight-based calculation for a drug dosage, particularly for a high-alert medication.
Some of our previous columns on improving stroke care:
March 2012 “Helicopter Transport and Stroke”
November 6, 2012 “Using LEAN to Improve Stroke Care”
March 18, 2014 “Systems Approach Improving Stroke Care”
June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”
September 23, 2014 “Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time”
January 27, 2015 “The Golden Hour for Stroke Thrombolysis”
May 12, 2015 “More on Delays for In-Hospital Stroke”
September 2015 “Stroke: Doing Less Well Than You Think?”
Barrow T, Khan MS, Halse O, et al. Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis. Stroke 2015; Published ahead of print November 10, 2015
NPSA (National Patient Safety Agency - UK). Reducing treatment dose errors with low molecular weight heparins. July 30, 2010
dos Reis Macedo LG, de Oliveira L, Pintão MC, et al. Error in body weight estimation leads to inadequate parenteral anticoagulation. Am J Emerg Med 2011; 29(6): 613-617
ISMP Canada. Vulnerabilities of Electronic Prescribing Systems: Height and Weight Mix-up Leads to an Incident with Panitumumab. ISMP Canada Safety Bulletin 2010; 10(5): 1-3 July 31, 2010
ISMP. Electronic prescribing vulnerabilities: Height and weight mix-up leads to dosing error. ISMP Medication Safety Alert! Acute Care Edition 2010; August 26, 2010
PPSA (Pennsylvania Patient Safety Authority), ECRI, ISMP. Medication errors: significance of accurate weights. Pennsylvania Patient Safety Advisory 2009; 6(1): 10-15 www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Mar6(1)/Pages/10.aspx
Finardi P, Nickel CH, Koller MT, Bingisser R. Accuracy of self-reported weight in a high risk geriatric population in the emergency department. Swiss Med Wkly 2012; 142: w13585
December 15, 2015
Vital Sign Monitoring at Night
A recent review of the literature shows that compliance with vital sign monitoring in hospitals in the UK is lower at night (Griffiths 2015). They found that even in patients with significant early warning scores, compliance with vital sign measurement at night was suboptimal.
The authors felt that nurses’ views regarding the importance of patient rest and the negative effects of sleep disruption may play a role in the lower compliance at night. We actually concur that, for many patients, waking them at night to check vital signs may be counterproductive (see our August 6, 2013 Patient Safety Tip of the Week “Let Me Sleep!”). In that column we noted a study which looked at ward inpatients stratified by the MEWS (Modified Early Warning Score) score (Yoder 2013). Patients with a MEWS score of 1 or less had an adverse event rate of 5.0 per 1000 patient-days whereas those with a MEWS score of 7 or more had an adverse event rate of 157.3 per 1000 patient-days. Yet the number of nighttime vital sign interruptions was no different, averaging 2 vital sign check per patient per night. At least one vital sign interruption occurred for 99% of nights. Almost half the nighttime vital sign interruptions occurred in patients with MEWS score of 1 or less.
The obvious implication was that we might be able to avoid sleep interruptions in a large proportion of hospitalized patients by tailoring vital sign frequency to the clinical risk profile of the patients, improving their sleep and overall health and, at the same time, potentially reducing costs associated with that monitoring.
But monitoring vital signs remains the major way in which we identify clinical deterioration. Griffiths and colleagues in the current study suggest risk stratification and use of electronic/automated vital sign collection as potential strategies to get more appropriate monitoring of vital signs at night. They note that implementation of early warning score charts has improved compliance but that compliance remains lower at night even when standardized protocols have been implemented (De Meester 2013).
A recent presentation at the American Heart Association meeting also noted that many patients having cardiopulmonary arrests at night who have shockable cardiac rhythms are not on cardiac monitoring. Luca Marengo and colleagues from University Hospital (Basel, Switzerland) found that only a third of such patients were monitored at their hospital (Hochron 2015). Marengo also discussed the possible use of risk stratification as a solution. Patients identified as deteriorating might be monitored whereas those who are improving might go unmonitored. As above, the study which looked at ward inpatients stratified by the MEWS (Modified Early Warning Score) score (Yoder 2013) found that patients with a MEWS score of 1 or less had an adverse event rate of 5.0 per 1000 patient-days whereas those with a MEWS score of 7 or more had an adverse event rate of 157.3 per 1000 patient-days. Use of stratification by a score such as the MEWS score thus conceivably could be used to help determine which patients need nighttime monitoring.
One potential solution to the dichotomy between allowing patients to sleep yet appropriately monitoring them is use of patient-worn devices that can automatically monitor EKG, heart rate, blood pressure, oxygen saturation, respiratory rate, temperature and other variables (Dombrowski 2014). However, as pointed out in response by Yoder and colleagues (Yoder 2014), it is not clear that such continuous monitoring would result in more uninterrupted sleep for patients. In fact, it could result in low-risk patients being wakened even more frequently.
A recent study reviewed the experience of two hospitals that implemented such continuous monitoring systems on med-surg wards (Watkins 2015). The authors found that such systems resulted in an average of 10.8 alarms per patient per day (not broken down by time of day). A survey of nurses on those units showed that nurses felt the number of alarms and alerts were appropriate and that the system improved patient safety. They also felt that the alarms may have initiated nursing interventions that prevented failure-to-rescue events. An important part of that implementation was that alarm thresholds and time to alert annunciations were based on prior analysis of the distribution of each vital sign. But we need to keep in mind that these are still relatively subjective outcomes. The study did not report actual adverse event rates. And it did not stratify patients by acuity level or score like the MEWS. We’d bet those authors could go back and calculate the MEWS scores and determine whether the alarm rates paralleled the MEWS risk scores.
All this, of course, presents us with a dilemma. On one hand, we are recommending reduction in the number of patients on telemetry in our attempts to minimize “alarm fatigue” (see our Patient Safety Tip of the Week for July 2, 2013 “Issues in Alert Management”). On the other hand, we don’t want to miss early identification of patients at risk.
As noted by Dombrowski (Dombrowski 2014), over the past decade hospital inpatients have been admitted for increasingly higher acuity and complex care, likely necessitating more rather than less monitoring.
We noted in our Patient Safety Tip of the Week for July 2, 2013 “Issues in Alarm Management” that one of the biggest opportunities every hospital has to reduce “alarm fatigue” is to reduce the volume of unnecessary telemetry. The American Heart Association and American College of Cardiology (AHA/ACC) have published guidelines on telemetry monitoring and suggested criteria. Yet many hospitals have never developed local guidelines to help identify which patients should be monitored (and which should not). Moreover, criteria for continued monitoring are extremely important because all too often a physician orders telemetry and it gets continued indefinitely. Getting your physician staff involved early in developing your telemetry criteria is the key.
One hospital system recently reported its results after it developed a system-wide policy based on the current American Heart Association (AHA) guidelines limiting the use of continuous cardiac monitoring (Rayo 2015). With strong leadership a cross-functional alarm management task force was able to create that system-wide policy. Their cardiac monitoring rate decreased 53.2%, monitored transport rate decreased 15.5%, ED patient boarding rate decreased 36.6%, and the percentage of false alarms decreased from 18.8% to 9.6%. Neither the length of stay nor mortality changed significantly after the policy was implemented.
The latter finding (i.e. that mortality and length of stay did not increase after implementing the policy) is particularly reassuring. It suggests that reduction in harm from alarm fatigue at least counterbalances any potential harm that might be caused by lack of continuous monitoring.
We suspect that the ultimate answer is somewhere between the two extremes of over- and under-monitoring. Our bet is that a system of continuous multiparameter monitoring such as that implemented by Watkins and colleagues can be stratified by a risk score such as the MEWS or by the AHA guidelines and meet both the need to identify patients at significant risk while reducing alarm fatigue.
As an aside, here is a useful exercise for you whether you do rounds solo in a community hospital or with a team in a teaching hospital: prior to rounds print out your rounding list from the electronic medical record. But instead of rounding by room number or patient name, do your primary sort on the frequency of vital signs. Then begin your rounds with those on whom you’ve ordered the most frequent vital signs. You’ll readily realize that patient on whom you are still doing q2h vital signs is walking up and down the hallway and probably doesn’t need q2h vital signs! Your patients and your nursing staff will appreciate it when you can then reduce the frequency of vital signs to a more appropriate level. This “rounds sorting” is a useful exercise you can do for other things, too (for example: patients with and without urinary catheters, or central lines, etc.)
Some of our other columns on MEWS or recognition of clinical deterioration:
Griffiths P, Saucedo AR, Schmidt P, Smith G. Vital signs monitoring in hospitals at night. Nursing Times 2015; 111(36/37): 16-17 02.09.15
Yoder JC, Yuen TC, Churpek MM, et al. A Prospective Study of Nighttime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration (Research Letter). JAMA Intern Med. 2013; 173(16): 1554-1555 Published online July 1, 2013
Dombrowski W. Acutely Ill Patients Will Likely Benefit From More Monitoring, Not Less. JAMA Intern Med 2014; 174(3): 475
Yoder JC, Arora VM, Edelson DP, et al. Acutely Ill Patients Will Likely Benefit From More Monitoring, Not Less—Reply. JAMA Intern Med 2014; 174(3): 475-476
Watkins T, Whisman L, Booker P. Nursing assessment of continuous vital sign surveillance to improve patient safety on the medical/surgical unit. Journal of Clinical Nursing 2015; Article first published online November 5, 2015
De Meester K, Das T, Hellemans K, et al. Impact of a standardized nurse observation protocol including MEWS after Intensive Care Unit discharge. Resuscitation 2013; 84(2): 184-188
Hochron A. Q&A With Luca Marengo From University Hospital Basel: Lack of Monitoring Hospital Patients At Night Can Have Fatal Consequences. HCPlive.com 2015; December 5, 2015
Rayo MF, Mansfield J, Eiferman D, et al. Implementing an institution-wide quality improvement policy to ensure appropriate use of continuous cardiac monitoring: a mixed-methods retrospective data analysis and direct observation study. BMJ Qual Saf 2015; Published Online First: 13 November 2015
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December 22, 2015
The Alberta Abbreviation Safety Toolkit
We haven’t done a full column on dangerous abbreviations since our July 14, 2009 Patient Safety Tip of the Week “Is Your 'Do Not Use' Abbreviations List Adequate?”. But dangerous abbreviations persist even as we’ve largely transitioned away from paper-based ordering systems to CPOE and e-prescribing.
Our interest was rekindled when we recently came across the Health Quality Council of Alberta (Canada) abbreviation toolkit (HQCA toolkit).
The Alberta abbreviations toolkit begins with a review of the literature, noting that the 5 abbreviations most often associated with errors are: “qd” (43%), “U” (13%), “cc” (13%), “MS” or “MSO4” (10%), and leading or trailing zeros (4%). It also provides links to the “do not use” lists from several quality and patient safety organizations. The toolkit also provides valuable materials such as focusing on high-alert medications or pediatric medications.
It then goes on to make recommendations about engaging the right people in your organization to implement a performance improvement initiative to reduce the use of dangerous abbreviations. These include recommendations about the role of leadership, clinical champions, and the actual implementation team. Further sections address measurement and planning for change. It has excellent sections on various strategies to use, audit and feedback, policies and guidelines, and education and training. Under strategies they include initiatives involving CPOE, forcing functions, standardization, pharmacy dispensing systems, and reminders. Forcing functions (or constraints) include not accepting any orders in which dangerous abbreviations appear.
In our July 14, 2009 Patient Safety Tip of the Week “Is Your 'Do Not Use' Abbreviations List Adequate?” we described our own experience with implementing a quality improvement project aimed at reducing the use of dangerous abbreviations. We began by noting that ISMP’s list of error-prone abbreviations, symbols and dose designations is considerably more comprehensive that Joint Commission’s list of “Do Not Use” abbreviations. We did a mini-survey of about 20 hospitals and could find none that used a list that went beyond Joint Commission’s minimum requirements. We jokingly refer to this as an “unintended consequence” of Joint Commission. Obviously, hospitals fear they will be cited if Joint Commission finds an occurrence of an abbreviation from an expanded list. But it’s really no joking matter. There are many potentially dangerous abbreviations on the ISMP list that are being condoned if an organization just goes with the Joint Commission minimalist list.
In reviewing a hospital’s “Do Not Use” abbreviation list for potential expansion, we found that about 4% of total orders had an abbreviation that appears on the ISMP list. More importantly, we found that about one in every seven verbal or telephone orders contained such an abbreviation.
So how does a healthcare organization go about expanding its “Do Not Use” list? The easy part is simply adopting all or part of ISMP’s list. The hard part is disseminating the new list, educating all appropriate healthcare workers about the list, implementing interventions to prevent their use, auditing and providing feedback, and measuring the impact. That process may take several months so setting a “go-live” date for policy implementation is wise when adopting such an expanded list. And it is critical to remember that these abbreviations do not just apply to orders. They apply to all forms of documentation, including history and physical exams, progress notes, discharge summaries, CPOE screens, standardized order sets, and electronic medical records, etc. They also should apply to your entire organization, both inpatient and outpatient. In particular, you also need to make sure that all your computer order entry screens do not contain any of the abbreviations you are adding to your list. Use of standardized order sets free of such dangerous abbreviations is a useful tool. Pay careful attention to all your pre-existing standardized order sets since we found these were a hidden source of many dangerous abbreviations. You would also be surprised at how often these abbreviations appear in software provided by third party vendors. Also, as we move into the “age of interoperability” you have to be wary that you don’t import documents and data from other hospitals and outside organizations that may contain some of the abbreviations you are trying to avoid.
After developing laminated pocket cards with the new list, developing screensavers with messages about dangerous abbreviations, and going to all departmental meetings (medical, nursing, and pharmacy) to discuss why we were doing this, we moved forward with the project. Every month the statistics were published and shared. The reports included the name of each provider who used one of the “do not use” abbreviations and these were shared with the department chairs and nursing supervisors. The medical director or department chair would then go over the abbreviations used with the individual physicians, advance practice nurses, or physician assistants. When meeting with them it is helpful to have examples (either from your own hospital or the literature) of a dangerous abbreviation that actually resulted in patient harm. We were able to keep the number of inappropriate abbreviations below the Joint Commission standard from the get-go and sustain that.
While we were largely able to keep dangerous abbreviations out of orders, it is much more difficult to keep them out of documentation like histories and physicals and progress notes. Some people have tried to downplay the importance of abbreviations in those documents, saying that they are dangerous only when in orders. That is absolutely not true. A discharge summary sent to a nursing home (or other post-discharge destination) with a discharge medication order that includes a dangerous abbreviation may well cause an error and patient harm at that next destination.
Propagation of such errors across transitions of care can also lead to patient harm. Physicians’ office notes, particularly handwritten notes, are notorious for containing dangerous abbreviations. In our June 12, 2007 Patient Safety Tip of the Week “Medication-Related Issues in Ambulatory Surgery” we noted the following story: “A patient came to an ambulatory surgery site for a procedure. Very little history had been provided prior to the patient’s arrival so on the day of the procedure staff asked the physician’s office to fax over some relevant office notes and the medication sheet. While hospitals have clearly begun to comply with the “do not use” abbreviation lists, most physician office notes are still replete with such abbreviations. The faxed notes were included in the facility medical record. The surgical procedure went well and the patient went home without incident or complication. However, 2 weeks later she was seen in the ER of the same hospital system for an unrelated problem. The patient’s primary physician was not available. The ER physician found in the patient chart copies of those office records that had been faxed in to the ambulatory surgery site. One of the medications listed in those records had a “qd” abbreviation that, perhaps in part because of fax artifact, looked like “qid”. The patient was admitted from the ER to the hospital and her maintenance medication that had been intended to be given once daily was now actually give four times daily. The error was not discovered until the patient developed symptoms of drug toxicity 5 days later. Well-performed medication reconciliation and compliance with the “do not use” list goal could have prevented this adverse outcome. But the case nicely illustrates how events in one part of the system can effect events in another part.” (See also our June 19, 2012 Patient Safety Tip of the Week “More Problems with Faxed Orders” for other examples of errors resulting from faxed orders.)
The abbreviations we had the most difficulty eliminating were the “>” and “<” symbols (“greater than” and “less than” symbols) and the “@” symbol. The latter, in particular, is an integral part of email addresses that are appearing more and more in various documents. So you may need to change your policy to allow the “@” sign when it is in an email address and only ban the “>” and “<” symbols when they are followed by a number.
Your monitoring process is also extremely important. Your Quality Improvement staff, medical records staff, and unit clerks can do spot checks of charts not only for orders but to make sure none of the documentation includes excluded abbreviations (also any charts you have selected for review via tracer methodology should be reviewed for unacceptable abbreviations). “Do not use” abbreviations are also one of the things we look for when doing patient safety walk rounds.
So don’t be satisfied that Joint Commission’s short list of dangerous abbreviations is all you need to meet. Do what’s right for patient care and look to eliminate all the abbreviations that have been shown to result in patient harm. Put together the right team and develop a plan to implement a more comprehensive approach to eliminating dangerous abbreviations. While Joint Commission always says it will hold you to “your own standards” we find it hard to believe they would actually ding you for going above and beyond and doing the right thing for patient care.
Some of our previous columns on the impact of abbreviations in healthcare:
March 12, 2007 “10x Overdoses”
June 12, 2007 “Medication-Related Issues in Ambulatory Surgery”
September 2007 “The Impact of Abbreviations on Patient Safety”
July 14, 2009 “Is Your “Do Not Use” Abbreviations List Adequate?”
April 2015 “Pediatric Dosing Unit Recommendations”
HQCA (Health Quality Council of Alberta). Writing it out can save a life. Let's stop the use of abbreviations in healthcare. Abbreviations Toolkit.
ISMP. List of Error-Prone Abbreviations, Symbols and Dose Designations.
The Joint Commission. Official “Do Not Use” List.
December 29, 2015
More Medical Helicopter Hazards
Time for our annual rant on safety issues related to medical helicopter/air ambulance transports. Since 2008 we’ve been doing columns pertinent to the rash of crashes of medical helicopter and air ambulance vehicles that we’ve seen in recent years with consequent loss of life of patients, staff and crew (see the full list of our prior columns at the end of today’s column).
Since our last column on helicopter/air ambulance accidents, there have been multiple subsequent accidents. The most recent one, leading to today’s column, occurred in California on December 10, 2015 (CBS/AP 2015). Four people, including a patient, a nurse, a paramedic, and the pilot died in that crash. That crash occurred during a planned 50-mile night flight in rainy, foggy conditions. Initial reports did not provide the medical reason the patient was being transported. A quick search on Google Maps estimates ground transport time between the two sites to be 49 minutes (though rainy, foggy conditions would be expected to likely increase that time as well). Without knowing the medical reason for transport or the equipment/staffing needs for the transport, we’re not in a position to comment on the most appropriate mode of transport in this case.
Actually, another one just occurred after we began work on this column. A medical helicopter crashed in Arizona, killing the pilot and a nurse and injuring a paramedic (Schwartz 2015). No patients were on board when the crash occurred. The helicopter was apparently returning to its base. Details are not known at this time.
A fatal crash in Oklahoma in March 2015 occurred in the setting of lower than expected cloud ceilings during a night flight (NTSB 2015a). A fatal crash of a twin-engined medical evacuation plane in New Mexico in August 2014 occurred after the plane was erroneously fueled with Jet A fuel instead of the required fuel (NTSB 2014a). An engine caught fire, leading to the crash, and four people including a patient, a nurse, a paramedic, and the pilot died in that crash. The patient had been staying in Las Cruces and receiving radiation therapy after having surgery for a brain tumor in a Phoenix hospital. He was being transported back to the Phoenix hospital after recent deterioration (Llorca 2014).
In March 2015 a helicopter attempting to land on a rooftop helipad at St. Louis University Hospital hit the edge of a hospital building and crashed in an adjacent parking lot, killing the pilot who was the only one aboard at the time (NTSB 2015b). The pilot had dropped off his crew and a patient previously, returned to his air base to refuel, and was now returning to the hospital to again pick up his crew. This was a night flight, with winds gusting to 25 knots, and the helicopter experienced loss of directional control.
In October 2014 a medical helicopter crashed in Wichita Falls, TX during a night flight in light winds (NTSB 2014b). The patient being transported died and 3 crew members were seriously injured. The pilot had aborted a first attempt at landing on the helipad, then went into a violent spin during the second attempt.
There are many factors that make accidents involving medical helicopters (and some other medical aviation) more likely to occur. Many medical flights occur at night or in inclement weather. The landing areas are also often not nice ample open spaces like airport runways, but are often rather tight spaces with wires and other obstacles nearby. The emergent nature of the medical mission often keeps the team from canceling the flight or diverting to safer routes. Most helicopter programs say that any crew member has the ability to call off the flight at any time but we wonder how often that really happens. The time pressures may be great. If you are trying to get a true level I trauma patient to a level I trauma center within the “golden hour”, or a rural stroke patient to a stroke center within the 3-hour therapeutic “window”, or an MI patient to a site for thrombolytic therapy or primary angioplasty site within their respective “windows”, time is of the essence. The same applies when transporting organs for transplantation.
Medical helicopters also are often flying without the benefit of air traffic controllers and sometimes without flight dispatchers. They most often fly by “sight” rules and have to visually look out for other aircraft and other obstacles. The NTSB report had pointed out that most medical helicopters do not make optimal use of night vision imaging systems or night vision goggles. Many medical helicopters also still do not utilize terrain awareness and warning systems, another safety feature recommended by the NTSB.
And you can add drones to the list of hazards as a drone in Pennsylvania almost collided with a medical helicopter (Choate 2014). There was no patient on board at the time. As the cost of personal drones has come down the number of drones being flown has increased significantly. A recent report counted at least 241 reports of close encounters between drones and manned aircraft that meet the Federal Aviation Administration's definition of a near-collision, including 38 that involved helicopters. (Lowy 2015). Helicopter blades are considered especially vulnerable if collisions were to occur. In New Hampshire a program was recently introduced requiring anyone operating a drone within 5 miles of Manchester-Boston Regional Airport to contact air traffic control before flying the drone (Brewer 2015). And the FAA just put forward a new rule requiring drone owners to register their drones by February 19, 2016 (Morgan 2015).
Surviving a medical helicopter crash may also be difficult for a number of reasons. Helmets, shown to help save lives and prevent head injuries in military helicopter crashes, are often not worn by all medical helicopter occupants. The same applies to shoulder harnesses. And there is some evidence that serious or fatal injuries are more likely to occur to those who are not in the front seats, that is those back in the cabin may be at more risk. And the lack of aviation flight risk evaluation programs by many helicopter EMS programs was also cited by the NTSB. They also noted that helicopter EMS accidents were more likely to occur when a patient is not on board (when rules and regulations are less stringent).
But the NTSB and FAA have been shortsighted and operated in a silo mentality in their analyses and approaches to the problem and the state and local regulatory agencies and even the medical community have done the same. Our September 1, 2009 Patient Safety Tip of the Week “The Real Root Causes of Medical Helicopter Crashes” pointed out that the only regulatory agency with any oversight of the medical helicopter industry is the FAA (Federal Aviation Administration) and, even then, it only has oversight of the aviation component. That column delved into some of the financial and other less altruistic incentives driving the industry.
Our issue #1 with the approaches taken by the NTSB and FAA to all these crashes has been that they have never asked the question “Was this method of transport necessary in the first place?”. They have focused only on the issues related to flights that they would address in their investigations of any aircraft crash or other transportation accident. Proposed solutions to these crashes have always focused on proximate causes and recommendations have come out in favor of mandating night vision goggles, terrain warning systems, better weather information, changes in pilot training, etc. Even the NTSB’s most recent communication addressing the need to do more to prevent the increasing frequency of helicopter accidents (NTSB 2014) fails to even mention the issue of necessity of the medical helicopter flights. It focuses on inspection and maintenance, crew fatigue, and the need for flight risk evaluation programs and formalized dispatch and flight-following procedures. Not a word about assessment of the medical necessity of air transport.
When we do a root cause analysis (RCA) of an event related to a medical or surgical procedure, one of the first questions we always ask is “Was the procedure indicated in the first place?”. When we approach the issues of CAUTI’s and CLABSI’s we ask the question “Was the catheter really necessary in the first place?”. No one is asking similar questions when reviewing medical transport crashes.
Ironically, on the very day we started preparing one of our 2009 columns, we chanced upon a medical helicopter evacuation scene. We couldn’t help but wonder if helicopter was the most appropriate means of transport. Judging by the state of the cars involved in the crash, it was pretty clear that the injuries suffered by someone were likely severe enough to merit transport to a Level I Trauma Center. By car from that spot is exactly 29 minutes in morning traffic (we know because we did that exact drive daily for over 12 years, where I was the medical director of the trauma hospital). It was a sunny day and the roads were dry, though it was a bit windy. It was not rush hour. Rather it was just shortly before 1PM. It would probably take the helicopter about 10 minutes to fly to the Trauma Center. We wondered how long it had taken the helicopter to arrive. The helicopter base site is about 30 miles from the accident site. The accident site was actually less than half a mile from another hospital so an ambulance was probably available within minutes of the accident. We don’t know if the victim had required extrication that might have added to any time elapsed. And we don’t know whether any specific medical expertise was required during that transport to the Trauma Center. The helicopter team is staffed by very well-trained EMT’s and we personally knew each of the very well-qualified medical directors who are available round-the-clock to provide medical guidance for the helicopter team. Yet we couldn’t help but wonder whether the total time elapsed to get the patient to the trauma center was faster by helicopter than it would have been had he/she been taken there by ambulance (keeping in mind that considerations other than speed may have also been important, such as staffing and equipment).
As above, all the solutions proposed by NTSB and the FAA ignore some of the most important root causes and failed to ask an important question “Was an air medical evacuation really necessary here or could ground ambulance have been adequate?”. Even the few root cause analyses (RCA’s) we have seen following actual medical helicopter crashes have failed to ask that fundamental question “Was the helicopter transport indicated in the first place?”.
We’ve several times noted a 2006 study done by Dr. Bryan Bledsoe and his colleagues that was a meta-analysis of helicopter transport of trauma patients (Bledsoe 2006). Using several widely-used injury severity or trauma scores, they showed that almost 2/3 trauma patients brought by helicopter to a trauma center had minor or non-life-threatening injuries and that 25% were discharged from the hospital within 24 hours. Some helicopter services apparently have rates as high as 20% of transported patients being discharged from emergency rooms shortly after arrival (Greene 2009). Even in Maryland, where the trauma system is a model and the medical helicopter system a public one, the post-crash hearings revealed that almost half of patients transported by helicopter to trauma centers were released within 24 hours (Dechter 2008).
In our March 2012 What's New in the Patient Safety World column “Helicopter Transport and Stroke” we noted that many patients with acute ischemic stroke or with acute MI are having thrombolytic therapy delayed pending helicopter transport to tertiary centers and finally reach those destinations beyond the therapeutic “windows” for successful intervention. Most hospitals on the “sending” end never even get feedback on either transport times or whether their patients got the desired therapies within the prescribed timeframes. For example, if a remote hospital is transporting a patient to a tertiary center for percutaneous coronary angioplasty for an MI and the statistics suggest that such patients seldom arrive within the standard window for PTCA, the remote hospital should consider giving thrombolytic therapy before sending the patient. The real question you should always be asking is “What’s the fastest way to get the patient/victim the medical interventions he needs?” and then assessing the risk:benefit ratio of air vs. ground transport.
Of course, it would also be nice to have a better understanding of how often crashes occur with ground ambulance transports. Such data are surprisingly hard to come by and are likely to be underreported (Ballan 2011). But it certainly seems there are a disproportionate number of medical helicopter/air ambulance accidents, given the relative frequencies of the two types of transport.
In view of the lack of effective oversight of the medical helicopter/air ambulance industry and the several potential conflicts of interest among key stakeholders (see our September 1, 2009 Patient Safety Tip of the Week “The Real Root Causes of Medical Helicopter Crashes”), the onus for reform falls either to (1) the public to put pressure on their state governments to develop oversight or (2) the hospital community to ensure appropriate use of such services. Good luck with the former! Unless a celebrity dies in such a crash it is unlikely that state legislatures will do anything.
So the task really falls to hospitals. Even if your organization does not own its own medical helicopter, there are things you can do to help ensure the safety of your staff and patients:
Medical helicopter/air ambulance transport can be lifesaving in innumerable cases. Yes, compared to the total number of transports, crashes of such aircraft are relatively few. But any time we might unnecessarily put lives at risk we need to be circumspect. We pay lots of attention to other medical “never events” (eg. wrong-site surgery, surgical fires, etc.) that are equally rare. Even if you don’t end up preventing a crash, doing the above exercises may alert you to problems in the referral-receiving relationships between hospitals that are leading to suboptimal care for your patients.
Our prior columns dealing with medical helicopter issues:
July 8, 2008 “Medical Helicopter Crashes”
October 2008 “More Medical Helicopter Crashes”
February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture”
September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes”
November 2010 “FAA Safety Guidelines for Medical Helicopters Short-Sighted”
March 2012 “Helicopter Transport and Stroke”
April 16, 2013 “Distracted While Texting”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
CBS/AP. 4 dead after medical helicopter crashes in heavy rain, fog. CBS News 2015; December 11, 2015
Schwartz D. Two killed, one critically hurt in medical helicopter crash in Arizona
Reuters 2015; December 16, 2015
NTSB (National Transportation Safety Board). NTSB Identification: CEN15FA171. March 12, 2015
NTSB (National Transportation Safety Board). NTSB Identification: CEN14FA462. August 27, 2014
Llorca JC. 4 killed in New Mexico crash of medical flight. Associated Press 2015;
August 28, 2014
NTSB (National Transportation Safety Board). NTSB Identification: CEN15FA164. March 6, 2015
NTSB (National Transportation Safety Board). NTSB Identification: CEN15FA003. October 4, 2014
Choate K. Close Call: Drone Nearly Collides With Medical Helicopter. PAhomepage.com 2014; November 21, 2014
Lowy J/Associated Press. Report cites 241 near collisions between pilots, drones. WFMJ 2015
Brewer R. WMUR. Manchester airport introduces new drone guidelines. WMUR News 2015; December 10, 2015
Morgan D. New U.S. FAA rule requires drone owners to register by Feb 19
Reuters 2015; December 14, 2015
NTSB (National Transportation Safety Board). NTSB Most Wanted List 2014. Address Unique Characteristics of Helicopter Operations. 2014
Bledsoe BE. Wesley AK. Eckstein M. Dunn TM. O'Keefe MF. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. Journal of Trauma-Injury Infection & Critical Care 2006; 60(6): 1257-1265
Greene J. Rising Helicopter Crash Deaths Spur Debate Over Proper Use of Air Transport. Annals of Emergency Medicine 2009; 53: A15-A17 (March 2009)
Dechter G, Jones B. Md. medevac crash raises question about trauma procedures. The Baltimore Sun. October 1, 2008
Ballan E. Ambulance Crash Roundup. EMS World. February 9, 2011
Maryland Institute for Emergency Medical Services Systems. The Maryland Medical Protocols for Emergency Medical Services Providers. Effective July 1, 2014
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Vital Sign Monitoring at Night
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July 21, 2015
July 14, 2015
July 7, 2015
June 30, 2015
June 23, 2015
June 16, 2015
June 9, 2015
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
May 5, 2015
April 28, 2015
April 21, 2015
April 14, 2015
April 7, 2015
March 31, 2015
March 24, 2015
March 17, 2015
March 10, 2015
March 3, 2015
February 24, 2015
February 17, 2015
February 10, 2015
February 3, 2015
January 27, 2015
January 20, 2015
January 13, 2015
January 6, 2015
December 30, 2014
December 23, 2014
December 16, 2014
December 9, 2014
December 2, 2014
November 25, 2014
November 18, 2014
November 11, 2014
November 4, 2014
October 28, 2014
October 21, 2014
October 14, 2014
October 7, 2014
September 30, 2014
More on Deprescribing
September 23, 2014
September 16, 2014
Focus on Home Care
September 9, 2014
September 2, 2014
August 26, 2014
August 19, 2014
August 12, 2014
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
July 22, 2014
July 15, 2014
July 8, 2014
July 1, 2014
Interruptions and Radiologists
June 24, 2014
June 17, 2014
June 10, 2014
June 3, 2014
May 27, 2014
May 20, 2014
May 13, 2014
May 6, 2014
April 29, 2014
April 22, 2014
April 15, 2014
Specimen Identification Mixups
April 8, 2014
April 1, 2014
March 25, 2014
March 18, 2014
March 11, 2014
March 4, 2014
February 25, 2014
February 18, 2014
February 11, 2014
February 4, 2014
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
January 7, 2014
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
December 3, 2013
November 26, 2013
November 19, 2013
November 12, 2013
November 5, 2013
October 29, 2013
October 22, 2013
October 15, 2013
October 8, 2013
October 1, 2013
September 24, 2013
September 17, 2013
September 10, 2013
September 3, 2013
August 27 2013
August 20 2013
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
June 11, 2013
June 4, 2013
May 28, 2013
May 21, 2013
May 14, 2013
May 7, 2013
April 30, 2013
April 23, 2013
April 16, 2013
April 9, 2013
April 2, 2013
March 26, 2013
March 19, 2013
March 12, 2013
March 5, 2013
February 26, 2013
February 19, 2013
February 12, 2013
February 5, 2013
January 29, 2013
January 22, 2013
January 15, 2013
January 8, 2013
January 1, 2013
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
December 11, 2012
December 4, 2012
November 27, 2012
November 20, 2012
November 13, 2012
November 6, 2012
October 30, 2012
October 23, 2012
October 16, 2012
October 9, 2012
October 2, 2012
September 25, 2012
September 18, 2012
September 11, 2012
September 4, 2012
August 28, 2012
August 21, 2012
August 14, 2012
August 7, 2012
July 31, 2012
July 24, 2012
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
June 26, 2012
June 19, 2012
June 12, 2012
June 5, 2012
May 29, 2012
May 22, 2012
May 15, 2012
May 8, 2012
May 1, 2012
April 24, 2012
April 17, 2012
April 10, 2012
April 3, 2012
March 27, 2012
March 20, 2012
March 13, 2012
March 6, 2012
February 28, 2012
February 21, 2012
February 14, 2012
February 7, 2012
January 31, 2012
January 24, 2012
January 17, 2012
January 10, 2012
January 3, 2012
December 20, 2011
December 13, 2011
December 6, 2011
November 29, 2011
November 22, 2011
November 15, 2011
November 8, 2011
November 1, 2011
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
September 27, 2011
September 20, 2011
September 13, 2011
September 6, 2011
August 30, 2011
August 23, 2011
August 16, 2011
August 9, 2011
August 2, 2011
July 26, 2011
July 19, 2011
July 12, 2011
July 5, 2011
June 28, 2011
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
May 24, 2011
May 17, 2011
May 10, 2011
May 3, 2011
April 26, 2011
April 19, 2011
April 12, 2011
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
March 15, 2011
March 8, 2011
March 1, 2011
February 22, 2011
February 15, 2011
February 8, 2011
February 1, 2011
January 25, 2011
January 18, 2011
January 11, 2011
January 4, 2011
December 28, 2010
December 21, 2010
December 14, 2010
December 6, 2010
November 30, 2010
November 23, 2010
November 16, 2010
November 9, 2010
November 2, 2010
October 26, 2010
October 19, 2010
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
September 7, 2010
August 31, 2010
August 24, 2010
August 17, 2010
August 10, 2010
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
July 20, 2010
July 13, 2010
July 6, 2010
June 29, 2010
June 22, 2010
June 15, 2010
June 8, 2010
June 1, 2010
May 25, 2010
May 18, 2010
May 11, 2010
May 4, 2010
April 27, 2010
April 20, 2010
April 13, 2010
April 6, 2010
March 30, 2010
March 23, 2010
March 16, 2010
March 9, 2010
March 2, 2010
February 23, 2010
February 16, 2010
February 9, 2010
February 2, 2010
January 26, 2010
January 19, 2010
January 12, 2010
January 5, 2010
December 29, 2009
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
November 24, 2009
November 17, 2009
November 10, 2009
November 3, 2009
October 27, 2009
October 20, 2009
October 13, 2009
October 6, 2009
September 29, 2009
September 22, 2009
September 15, 2009
September 8, 2009
September 1, 2009
August 25, 2009
August 18, 2009
August 11, 2009
August 4, 2009
July 28, 2009
July 21, 2009
July 14, 2009
July 7, 2009
June 30, 2009
June 23, 2009
June 16, 2009
June 9, 2009
June 2, 2009
May 26, 2009
May 19, 2009
May 12, 2009
May 5, 2009
April 28, 2009
April 21, 2009
April 14, 2009
April 7, 2009
March 31, 2009
March 24, 2009
March 17, 2009
March 10, 2009
March 3, 2009
February 24, 2009
February 17, 2009
February 10, 2009
February 3, 2009
January 27, 2009
January 20, 2009
January 13, 2009
January 6, 2009
December 30, 2008
December 23, 2008
December 16, 2008
December 9, 2008
December 2, 2008
November 25, 2008
November 18, 2008
November 11, 2008
November 4, 2008
October 28, 2008
October 21, 2008
October 14, 2008
October 7, 2008
September 30, 2008
September 23, 2008
September 16, 2008
September 9, 2008
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
August 5, 2008
July 29, 2008
July 22, 2008
July 15, 2008
July 8, 2008
July 1, 2008
June 24, 2008
June 17, 2008
June 10, 2008
June 3, 2008
May 6, 2008
April 29, 2008
April 22, 2008
April 15, 2008
April 8, 2008
April 1, 2008
March 25, 2008
March 18, 2008
March 11, 2008
March 4, 2008
February 26, 2008
February 19, 2008
February 12, 2008
February 5, 2008
January 29, 2008
January 22, 2008
January 15, 2008
January 8, 2008
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
December 4, 2007
November 20, 2007
November 13, 2007
November 6, 2007
October 30, 2007
October 23, 2007
October 16, 2007
October 9, 2007
October 2, 2007
September 25, 2007
September 18, 2007
September 11, 2007
September 4, 2007
August 28, 2007
August 21, 2007
August 14, 2007
August 7, 2007
July 31, 2007
July 24, 2007
July 17, 2007
July 10, 2007
July 3, 2007
June 26, 2007
June 19, 2007
June 12, 2007
June 5, 2007
May 29, 2007
May 22, 2007
May 15, 2007
May 8, 2007
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
April 2, 2007
March 26, 2007
March 19, 2007
March 12, 2007
March 5, 2007
February 26, 2007