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January 24, 2023
Tale of 2 Graces
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a healthcare mix-up of a hockey player and a basketball player, both named Tyler Ennis. X-rays of one Tyler Ennis were mistaken for those of the other Tyler Ennis. Fortunately, there were no adverse consequences from the mix-up but there could have been.
While it is not, per se, a patient safety example, a recent Kaiser Health News story (Kreidler 2022) showed how the same type of patient misidentification can lead to nightmares for a patient. The snafu involved 31-year-old Grace E. Elliott and 81-year-old Grace A. Elliott. Grace E. had a hospital visit with a small bill 8 years earlier while visiting her parents in Venice, Florida. Grace A. had an expensive shoulder replacement at the same hospital years later. But a bill addressed to Grace E. was sent to Grace E’s mother with charges for a shoulder replacement (Grace E. was no longer living in Florida). Initially suspecting possible identity theft, Grace E. contacted the hospital. After several weeks and multiple phone calls, the corporate office for the hospital let Grace E. know of the hospital’s error and promised to correct it. But, in the interim, the account had been turned over to a collection agency and the misidentification was not communicated to the collection agency. Two appeals to the collection agency were denied. It was only after involvement of a reporter that the snafu was ultimately resolved. In all, it took nearly a year of hours-long phone calls to undo the damage.
In addition to the patient identification error, there were obviously communication errors. Hospital ownership had changed, and the hospital had actually closed prior to this case being resolved. Moreover, in one of the collection agency’s denial letters several pages of the older woman’s medical information were disclosed (certainly sounds to us like there may be HIPAA implications). Though the case involves billing records, the latter issue also raises the question about whether any medical information has been incorrectly included in the medical records of either or both of these patients.
Correct patient identification is the responsibility of all hospital personnel, not just clinicians. Two-factor identification is the minimum requirement. Most hospitals and healthcare facilities use patient name and date of birth as the two identifiers. Grace E. and Grace A. had different dates of birth. But even using date of birth may not be an adequate safeguard. In our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” we noted a near-miss when two patients had the same name and same date of birth and noted the fact that, in one hospital district in Texas, 2488 patients were named Maria Garcia, and 231 of these (9.3%) also shared the same date of birth! (Lippi 2017).
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a glaring example of how patient photographs in the EMR might prevent a wrong patient error. Obviously in the current case photographs could also have easily distinguished patients of widely different ages.
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” also has a discussion on how a long-overdue national patient identifier (NPI) system could serve as a means of preventing patient misidentification.
We recommend you read the entire Kaiser Health News story (Kreidler 2022) for all the details of the current example. This is an excellent story you should include in your orientation of non-clinical personnel in your organization to emphasize the importance of correct patient identification at all times.
Some of our prior columns related to patient identification issues:
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
November 17, 2009 “Switched Babies”
July 17, 2012 “More on Wrong-Patient CPOE”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
August 2015 “Newborn Name Confusion”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
August 1, 2017 “Progress on Wrong Patient Orders”
June 19, 2018 “More EHR-Related Problems”
November 2018 “More on Hearing Loss”
March 26, 2019 “Patient Misidentification”
May 21, 2019 “Mixed Message on Number of Open EMR Records”
September 10, 2019 “Joint Commission Naming Standard Leaves a Gap”
December 17, 2019 “Tale of Two Tylers”
March 24, 2020 “Mayo Clinic: How to Get Photos in Your EMR”
June 16, 2020 “Tracking Technologies”
November 17, 2020 “A Picture Is Worth a Thousand Words”
August 3, 2021 “Obstetric Patients More At-Risk for Wrong Patient Orders”
Some of our prior columns on use of patient photographs in patient safety:
December 2008 “Patient Photographs Improve Radiologists’ Performance”
January 12, 2010 “Patient Photos in Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
January 19, 2016 “Patient Identification in the Spotlight”
March 26, 2019 “Patient Misidentification”
November 12, 2019 “Patient Photographs Again Help Radiologists”
December 17, 2019 “Tale of Two Tylers”
March 24, 2020 “Mayo Clinic: How to Get Photos in Your EMR”
November 17, 2020 “A Picture Is Worth a Thousand Words”
References:
Kreidler M. The case of the two Grace Elliotts: A medical billing mystery. Kaiser Health News 2022; December 21, 2022
https://khn.org/news/article/mistaken-identity-two-grace-elliotts-medical-billing-mystery/
Lippi G, Chiozza L, Mattiuzzi C, Plebani M. Patient and Sample Identification. Out of the Maze? J Med Biochem 2017; 36(2): 107-112. Published online 2017 Apr 22
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471642/
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January 31, 2023
Alert on Oxygen Cylinder Use
We’ve written about problems with oxygen cylinders in several columns (see our What's New in the Patient Safety World columns for November 2016 “Oxygen Tank Monitoring” and February 2018 “Oxygen Cylinders Back in the News”). And, of course, running out of oxygen during patient transports was a major reason that the “Ticket to Ride” checklist was developed (see below for our many columns on the “Ticket to Ride”).
England’s NHS (National Health Service) recently issued a patient safety alert regarding oxygen cylinders (NHS 2023). NHS saw an increased number of incidents involving oxygen cylinders as there was a surge in demand for oxygen for respiratory-related illnesses. That surge raised issues around oxygen cylinders regarding not only patient safety, but also fire safety and physical safety. It found 120 patient safety incidents related to oxygen cylinders over a 12 month period. These included incidents such as:
Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest. In addition, there is a need to conserve oxygen cylinder use to ensure a robust supply chain process.
NHS recommends that hospitals and healthcare facilities undertake a risk assessment, including attention to the following:
NHS also notes that priority should be given to escalation/transient areas being used to acutely care for patients (eg corridors, non-inpatient areas such as physiotherapy departments, ambulances outside emergency departments).
NHS had also just released a guidance “Safe Use of Oxygen Cylinders” that stresses patient safety issues, fire safety, physical safety, and conservation of resources. It begins by reminding us that oxygen treatment should be optimized to target saturation ranges as recommended in BTS Guideline for oxygen use in adults in healthcare and emergency settings (O'Driscoll 2017). Fixed performance (or "Venturi") masks should be used preferentially to ensure that oxygen saturations remain within the target range. Organizations should ensure that these are available in sufficient quantities. NHS England support patients requiring CPAP or non-invasive ventilation, especially if in an ambulance, to be prioritized for transfer to a clinical area where oxygen via the MGPS (medical gas pipeline systems) is available. If this is not possible, use the lowest flow device available. It stresses ongoing clinical checks, with oxygen saturation checks using appropriate oximeter positioning and probes, and both initial and regular flow checks to ensure oxygen is flowing to the patient.
Regarding patient safety issues, it recommends:
Because of the current supply issue, the guidance notes it is important the cylinders are used until the cylinder content display is nearing empty, to ensure maximal use. But that also has important patient safety implications. It is therefore essential when using any oxygen cylinder to always check the cylinder contents display and estimate the approximate residual volume according to the prescribed flow rate. (A generic guide covering commonly used cylinders can be downloaded and displayed in clinical areas or laminated and tagged to standalone cylinders). Care must be taken that cylinders do not fully empty, and patients no longer receive oxygen. On transfer: ensure patients requiring oxygen are transferred with an oxygen cylinder and that there is sufficient oxygen left to facilitate the transfer and/or the time to undertake diagnostic tests. That is a point we emphasize in our columns on the “Ticket to Ride” checklist. On arrival to ward, ensure patient is attached to oxygen via MGPS (medical gas pipeline systems), eliminating the risk of inadvertent connection to medical air via a flowmeter and oxygen cylinders are returned as soon as possible.
Regarding physical safety issues, the guidance recommends:
The NHS guidance discusses fire safety issues as well. It recommends:
Our October 2022 What's New in the Patient Safety World column “Portable Oxygen and Ambulance Fire” discussed the role of portable oxygen in a fatal ambulance fire. The recent NHS guidance specifically addresses the use of oxygen in ambulances, noting that prolonged use of supplemental oxygen in an enclosed ambulance “saloon” may increase the risk of fire due to raised ambient oxygen concentrations. To minimize this risk the following should be considered:
With extended use of supplemental oxygen in the ambulance “saloon” it may be necessary to change onboard cylinders during deployment. Care should be taken to ensure that all valves, regulators and fitments are clean, dry and free from grease or any other contaminant before re-attachment to a cylinder. Following reattachment, valves should be opened slowly into an open supply, i.e. with the flowmeter open, to reduce the risk of fire or explosion from “adiabatic compression” – following instructions for use available for medical gas cylinder supplier. It provides a link to a very interesting discussion about an oxygen cylinder that caught fire whilst being prepared for a patient who was being transferred to another hospital (Kelly 2014). That fire seemed to arise from within the cylinder and they discuss and the article discusses both the potential fuels within a cylinder plus the “adiabatic” heating of the gases that could lead to combustion.
Don’t forget oxygen cylinders have been projectiles in fatal MRI accidents (see our many columns on MRI safety listed below). We’ve also recommended you carry out simulations or drills with your local police or fire departments. You don’t want any of their personnel entering an MRI suite with an oxygen cylinder.
Our February 2018 What's New in the Patient Safety World column “Oxygen Cylinders Back in the News” was triggered by a previous NHS safety alert based on over 400 incidents involving oxygen cylinders. We hope you’ll go back to that column for our comments. We criticized that NHS alert because the recommended actions were primarily educational, and we’ve often pointed out that educational interventions are among the least effective interventions. We are pleased to see that the current NHS alert goes well beyond recommendations for educational interventions.
The current “tripledemic” of respiratory illnesses has undoubtedly resulted in potential problems in use, storage, and transport of oxygen cylinders. Now is a good time to review your own vulnerabilities to incidents involving oxygen cylinders. Even if you don’t have a Medical Gas Committee you should at least incorporate assessment of oxygen cylinders into your Patient Safety Walk Rounds (not only assessing cylinders in storage areas but also checking safety issues any time you find an oxygen cylinder with a patient during an intrahospital transport). And for those of you looking for a topic for a FMEA (Failure Mode and Effects Analysis), this is a good topic.
Some of our prior columns on potential harmful effects of oxygen and other oxygen issues:
April 8, 2008 “Oxygen as a Medication”
January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”
April 2009 “Nursing Companion to the BTS Oxygen Therapy Guidelines”
October 6, 2009 “Oxygen Safety: More Lessons from the UK”
July 2010 “Cochrane Review: Oxygen in MI”
December 6, 2011 “Why You Need to Beware of Oxygen Therapy”
February 2012 “More Evidence of Harm from Oxygen”
March 2014 “Another Strike Against Hyperoxia”
June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”
December 2014 “Oxygen Should Be AVOIDed”
August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”
November 2016 “Oxygen Tank Monitoring”
November 2016 “More on Safer Use of Oxygen”
October 2017 “End of the Oxygen in MI and Stroke Debate?”
February 2018 “Oxygen Cylinders Back in the News”
June 2018 “Too Much Oxygen”
July 2021 “Unique Way to Rapidly Identify Oxygen Flow”
October 2022 “Portable Oxygen and Ambulance Fire”
January 2023 “Oxygen During Surgery”
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
Some of our prior columns on patient safety issues related to MRI:
References:
NHS England. Patient Safety Alert. Use of oxygen cylinders where patients do not have access to medical gas pipeline systems. NHS England 2023; January 10, 2023
NHS England. Safe Use of Oxygen Cylinders. NHS England 2023; 5 January 2023, Version 1
O'Driscoll BR, Howard LS, Earis J on behalf of the British Thoracic Society Emergency Oxygen Guideline Group, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72(Supplement 1): ii1-ii90
https://thorax.bmj.com/content/72/Suppl_1/ii1
Kelly, F.E., Hardy, R. and Henrys, P. Oxygen cylinder fire – an update. Anaesthesia 2014; 69: 511-513
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.12698
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February 7, 2023
Reducing Unnecessary Telemetry
When hospitals ask “Where should we start?” in addressing alarm fatigue, we always tell them the first place to look is at unnecessary telemetry. There are two key elements in programs to reduce such use:
A hospital system recently did just that (Patidar 2022). They did 2 key interventions across 4 hospitals (a large academic quaternary center, a tertiary care center, a small community hospital, and a large community hospital) with a total of 1700 beds. The 2 key elements were:
There was a statistically and clinically significant 24% decrease in telemetry duration between pre- and post-intervention time periods (P < 0.0001). Mean telemetry duration was 4.11 and 2.36 days in pre- and post-intervention periods, respectively, a 1.75 day reduction across each of the four hospitals.
The authors projected a substantial cost avoidance from this project. Though they did not measure it, there was also likely also a substantial reduction in alarm fatigue as a result of the project.
The Patidar article details the project planning by a multidisciplinary team and the communication rollout that was important in preparing for the implementation of the automated protocol.
The results are remarkably similar to a program we highlighted in our October 2014 What's New in the Patient Safety World column “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”, in which researchers at Christiana Care Health System successfully reduced unnecessary non-ICU telemetry and achieved substantial financial savings while not adversely impacting patient safety (Dressler 2014). A multidisciplinary team designed the program and ensured appropriate training of impacted departments. The key component was hardwiring the AHA guidelines into their electronic ordering system. Providers were now required to choose an indication from a list, each of which included a duration based upon the AHA guidelines. In addition, they removed telemetry orders from order sets for conditions where monitoring was not supported by the AHA guidelines. Also, guidelines were established for automatic discontinuation of telemetry monitoring. After implementation there was a 70% reduction in the mean daily number of patients being monitored by telemetry. The mean weekly number of telemetry orders dropped 43% and the mean duration of telemetry dropped by 47%.
Another striking reduction in telemetry was achieved on a hospitalist service (Edholm 2018). Interventions included education, process change, routine feedback, and a financial incentive. A system-wide change to the telemetry ordering process was also introduced without the other components. Among hospitalist service patients, telemetry utilization was reduced by 69%. On the non-hospitalist services the reduction was a less marked 22%. There were no significant increases in mortality, code event rates, or care escalation, and there was a trend toward improved utilization appropriateness. The EHR telemetry order was modified to discourage unnecessary telemetry monitoring. The new order required providers ordering telemetry to choose a clinical indication and select a duration for monitoring, after which the order would expire and require physician renewal or discontinuation. These were the only changes that occurred for nonhospitalist providers.
The authors also noted there had been an immediate decrease in telemetry orders after removing the telemetry order from their admission order set. They also attributed success on the hospitalist service to standardization of rounds to include daily discussion of telemetry and the provision of routine feedback. They could not discern whether other components of the program (such as the financial incentives) contributed more or less to the program, though the sum of these interventions produced an overall program that required substantial buy in and sustained focus from the hospitalist group.
Our own take on these programs is that there are some key success factors:
Though such programs likely achieve significant financial savings, you staffs are more likely interested in outcomes other than financial ones. Though measurement of alarm fatigue is difficult, you can at least do informal surveys of stakeholders about the perceived benefit as it pertains to alarm fatigue.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
Some of our prior columns on the hazards associated with telemetry:
References:
Patidar V, Park JM, Khasnavis T, et al. Evaluation of a Multifaceted Protocol in Reducing Unnecessary Telemetry Monitoring Across a Large Healthcare System. South Med J 2022; 115(12): 930-935
Dressler R, Dryer MM, Coletti C, et al. Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines. (Research Letter). JAMA Intern Med 2014; 174(11): 1852-1854 published online first September 22, 2014
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1906998
Edholm K, Kukhareva P, Ciarkowski C, et al. Decrease in Inpatient Telemetry Utilization Through a System-Wide Electronic Health Record Change and a Multifaceted Hospitalist Intervention. Journal of Hospital Medicine 2018; 13: 531-536
https://shmpublications.onlinelibrary.wiley.com/doi/abs/10.12788/jhm.2933
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February 14, 2023
Code Terminology Still Problematic
In our September 18, 2007 Patient Safety Tip of the Week “Wristbands: The Color-Coded Conundrum” we noted the lack of standardization of color-coding of wristbands was problematic. Problems may arise when a healthcare worker who usually works at another facility is now exposed to a colored wristband at a new facility that has a different meaning.
The same problem can occur with the nomenclature of emergency “codes”. In our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” we noted a good piece of advice from the Minnesota Hospital Association (MHA 2011). Most of you are aware of the movement to replace “codes” with plain language for paging emergencies in hospitals (and other healthcare settings). Again, that is because a “Code Yellow” may mean one thing at one hospital and a different thing at another hospital.
So, are we doing any better? Apparently not, according to a new study. Harris et al (Harris 2022) sought to assess the ability of clinical and non-clinical employees across the State of Georgia to correctly identify their facility’s emergency codes.
Anonymous electronic surveys asked 304 employees at 5 facilities to identify the codes for 14 different emergencies. Participants correctly identified the emergency codes with only 44.37% accuracy on average. Codes for fire, infant abduction, and cardiac arrest were most commonly identified correctly (≥90%). Codes for hostage situation, internal disaster, pediatric emergency, and mass casualty incident were incorrectly identified by more than 85% of participants.
They also sought to identify significant predictors of emergency code identification accuracy. Code identification accuracy was significantly higher in participants who received training at employee orientation, had knowledge of emergency code activation procedures, and had worked at their current facility for two to five years. However, accuracy was lower in employees who had worked at four to five facilities in their careers, suggesting that code confusion becomes particularly pronounced after having more than three healthcare employers.
They also assessed employees’ opinions of emergency alert systems. Most survey participants favored a color-code-based alert system over a plain language-based alert system, citing concerns of causing panic in patients and visitors, and of maintaining confidentiality and discretion. But, obviously, the color-code-based systems are not cutting it. Most code systems in the US use color-based codes (e.g., “Code Red” for a fire), predicated on the idea that colors are easier to remember and serve as a tool to increase encoding among a target audience. But individuals often associate specific colors with specific images that may not be universal.
Harris et al. point out that approximately one in five healthcare workers has at least two jobs, and each employer may have its own emergency code designations. Moreover, staffing issues have resulted in many new or temporary healthcare workers at any facility, particularly since the COVID-19 era began.
Hospital associations in more than 25 states in the US have recommended the introduction of a standardized set of emergency codes and multiple hospital associations have advocated using “plain language” codes (Wallace 2015).
There is currently no national standard in the United States for such warning systems in healthcare facilities. Harris et al. conclude that transitioning to plain language overhead emergency alerts will better position employees, as well as patients and visitors, to effectively respond to emergencies and disasters occurring within a healthcare facility. They note that both the U.S. Federal Emergency Management Agency (FEMA) and the Department of Health and Human Services (DHHS) advocate for plain language communications in all emergency and disaster communications.
The commonly cited reasons against plain language-based alerts are fear of causing panic in patients and visitors, and of maintaining confidentiality and discretion. We’ll counter that by noting that patients and visitors can play an important role in resolution of the incident leading to the alert. They might not know what a “Code Gray” or “Code Pink” means, but they could certainly help identify a wandering patient or abducted infant if the alert was more specific.
The Harris study showed that both clinical and non-clinical employees have limited accuracy in identifying their hospital’s emergency codes. Code identification accuracy was significantly associated with training at orientation, knowledge of emergency code activation procedures, facility experience, and total facilities in the career. The majority of survey participants favored a code-based alert system over a plain language-based alert system, citing concerns of causing panic in patients and visitors and maintaining confidentiality and discretion. The Harris study and the Wallace study cite several other studies demonstrating “code confusion”.
Hasn’t the time come for standardization of emergency alerts in healthcare? While the time-honored use of colors in naming codes could be standardized, we strongly favor transition to plain language-based alerts.
References:
MHA (Minnesota Hospital Association). Plain Language Overhead Emergency Paging. Implementation Toolkit. 2011
http://www.mnhospitals.org/Portals/0/Documents/ptsafety/overhead-paging-toolkit-2011.pdf
Harris C, Zerylnick J, McCarthy K, et al. Breaking the Code: Considerations for Effectively Disseminating Mass Notifications in Healthcare Settings. Int J Environ Res Public Health 2022; 19(18): 11802
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9517086/
Wallace SC, Finley E. Standardized Emergency Codes May Minimize “Code Confusion”. Pa Patient Saf Advis 2015; 12(1): 1-6
http://patientsafety.pa.gov/ADVISORIES/Pages/201503_01.aspx
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What's New in the Patient Safety World
Appropriate use of oxygen therapy is important. Several of our prior columns on use of oxygen in non-hypoxemic patients have shown the potential for untoward side effects.
A new study (McIlroy 2022) analyzed data on over 250,000 adult patients undergoing surgical procedures ≥120 minutes’ duration with general anesthesia and endotracheal intubation at 42 medical centers across the United States. These medical centers were participating in the Multicenter Perioperative Outcomes Group data registry. Excess use of oxygen was defined as oxygen concentrations greater than 21% for any period during which oxygen saturation was greater than 92%.
After accounting for baseline covariates and other potential confounding variables, increased oxygen exposure was associated with a higher risk of acute kidney injury, myocardial injury, and lung injury.
Patients at the 75th centile for the area under the curve of the fraction of inspired oxygen had 26% greater odds of acute kidney injury, 12% greater odds of myocardial injury, and 14% greater odds of lung injury compared with patients at the 25th centile.
Secondary outcomes included 30-day mortality, hospital length of stay, and stroke. Increased supraphysiological oxygen administration was associated with stroke (p<0.001) and 30-day mortality (p=0.03), independent of all factors included as covariates. Patients at the 75th centile compared to those at the 25th centile of excess oxygen exposure had 9% greater odds of stroke and 6% greater odds of 30-day mortality.
Increased supraphysiological oxygen administration was associated with decreased
hospital length of stay (p<0.001). Patients at the 75th centile had a 0.20 day shorter length of stay compared to those at the 25th centile (even after excluding those patients who died prior to discharge). The authors did not comment on potential reasons for this. It’s a bit unexpected. Usually, we see an increase in LOS when there is an increase in complications. Since kidney and myocardial damage were identified by lab values, perhaps these were not clinically significant enough to impact LOS.
The researchers conclude that a large clinical trial to detect small but clinically significant effects on organ injury and patient centered outcomes is needed to guide oxygen administration during surgery.
Just one more example that you can have “too much of a good thing”. We need to use sound judgement when we use supplemental oxygen in any setting.
Some of our prior columns on potential harmful effects of oxygen and other oxygen issues:
April 8, 2008 “Oxygen as a Medication”
January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”
April 2009 “Nursing Companion to the BTS Oxygen Therapy Guidelines”
October 6, 2009 “Oxygen Safety: More Lessons from the UK”
July 2010 “Cochrane Review: Oxygen in MI”
December 6, 2011 “Why You Need to Beware of Oxygen Therapy”
February 2012 “More Evidence of Harm from Oxygen”
March 2014 “Another Strike Against Hyperoxia”
June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”
December 2014 “Oxygen Should Be AVOIDed”
August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”
November 2016 “Oxygen Tank Monitoring”
November 2016 “More on Safer Use of Oxygen”
October 2017 “End of the Oxygen in MI and Stroke Debate?”
February 2018 “Oxygen Cylinders Back in the News”
June 2018 “Too Much Oxygen”
July 2021 “Unique Way to Rapidly Identify Oxygen Flow”
References:
McIlroy D R, Shotwell M S, Lopez M G, Vaughn M T, Olsen J S, Hennessy C et al. Oxygen administration during surgery and postoperative organ injury: observational cohort study BMJ 2022; 379: e070941
https://www.bmj.com/content/379/bmj-2022-070941
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Nudges, when provided correctly, can often be an effective means to help achieve desirable outcomes. We’ve given several examples in the columns noted below.
Researchers at Penn Medicine recently demonstrated successful use of EHR-delivered nudges to improve prescribing statins to patients where statin therapy was indicated. Because statins are often underutilized in patients who may benefit from them, Adusumalli and colleagues (Adusumalli 2022) performed a cluster randomized clinical trial of 4131 patients from 28 primary care practices affiliated with Penn Medicine who met criteria for statin use in guidelines. Nudges were provided to primary care clinicians, patients, or both and results were compared with groups having no nudges. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message delivered 4 days before the visit. The combined nudge included the clinician and patient nudges.
During the intervention, statins were prescribed to 7.3% of patients in the usual care group, 8.5%, in the patient nudge group, 13.0% in the clinician nudge arm, and 15.5% in the combined group. So, the clinician nudge improved statin prescribing and the combined nudge (clinician and patient) was even more successful. But the patient nudge alone did not improve statin prescribing. Prescribing rates improved in the clinician-only and clinician -plus-patient nudge groups compared with usual care, by 5.5 and 7.2 absolute percentage points, respectively.
But success was likely due to more than just the targets of the nudges. The timing and content were important. Rather than presenting the nudge when the clinician logged on to the EHR, the nudge appeared when the clinician went to the ordering page of an eligible patient. And it was presented with a calculation of the patient’s risk and a chart with statin dosing options. That made it easier for the clinician to order a statin without an interruption in workflow. The timing of the patient nudge may also have been important. It was delivered via text message starting 4 days before their appointment, reminding them of the upcoming appointment and informing them of an important message about their heart health. Patients had to reply to confirm their willingness to communicate by text, and if so, they were told that “guidelines indicate you should be taking a statin to reduce the chance of a heart attack” and about the benefits of lowering cholesterol and the rare adverse effects that go away upon stopping the medication. Patients were told that “at Penn Medicine, it is standard of care to prescribe a statin to patients like you.” Patients were asked to reply “Y” if they were interested in taking a statin or reply “?” if they were unsure or had questions for the physician. Patients replying “Y” were told to remember to discuss the statin during their visit and sent a link to a shared decision-making tool on statin therapy. While nudging the patient alone did not improve statin prescribing, it probably set the stage for appropriate discussion with those clinicians who also were nudged.
One other likely success factor was that the active choice prompt in the EHR to clinicians was codesigned by leadership and frontline clinicians in the health system.
We like this nudge. Although the improvements might seem modest, the accompanying editorial (Ahmad 2022) notes that this occurred against a background high baseline prescription rate of statins in the statin-eligible population (approximately 70%) and the majority of untreated patients were candidates for primary, not secondary, prevention, making this group of patients particularly challenging for seeing large effect sizes of interventions.
See some of our other columns dealing with “nudges”:
References:
Adusumalli S, Kanter GP, Small DS, et al. Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial. JAMA Cardiol 2022; Published online November 30, 2022
https://jamanetwork.com/journals/jamacardiology/fullarticle/2798971
Ahmad FS, Persell SD. Nudging to Improve Cardiovascular Care—Clinicians, Patients, or Both. JAMA Cardiol 2022; Published online November 30, 2022
https://jamanetwork.com/journals/jamacardiology/article-abstract/2798974
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For many years, when we would do our patient safety orientation to our incoming residents, we had one slide that said “Never Assume – It will make an “Ass” out of “U” and “Me”. We came across a recent sad story of how an assumption probably led to a premature death of a patient.
A woman in her 80’s was hospitalized in Japan in December 2017 with a femur fracture and underwent a CT scan (Mainichi 2022). A doctor in the diagnostic radiology department noticed the suspicion of lung cancer and compiled an examination report. However, the attending orthopedic surgeon reportedly did not read the report because the woman's fracture surgery had already been completed. In December 2021, the woman was hospitalized again for a lumbar compression fracture. The same radiologist prepared a report acknowledging the suspicion of lung cancer, but mistakenly assumed that her cancer treatment had already begun and failed to alert her attending physician, a different orthopedic surgeon from 2017. The surgeon reportedly only looked at the CT of the lumbar spine and failed to check the report. In May 2022, the woman was again transported to a hospital for suspected heart failure. Because of fluid in her lungs, a respiratory physician checked the two previous reports and found the description of suspected lung cancer. However, it was too late and the patient died. The hospital director apologized, saying, "If she had started treatment earlier, she might have survived."
Such assumptions are a sure way to court similar disasters. In our numerous columns on communicating significant results to avoid patients “falling through the cracks”, we have emphasized the need for multiple people to have systems in place to ensure the message does not get lost. Every radiology department must have in place a system that ensures the message about the suspicious imaging finding was received by the ordering clinician (or clinician who will be providing ongoing care).
See also our other columns on communicating significant results:
References:
Patient dies after info-sharing error at Japan hospital delays cancer diagnosis for 4.5 yrs. The Mainichi 2022; November 25, 2022
https://mainichi.jp/english/articles/20221125/p2a/00m/0na/011000c
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We often talk about the importance of “hearback” in aviation or in the OR or other medical situations. But hearback is also important in our communications with our patients. Hearback is much more than simply having someone repeat back what you said to them. It is ensuring that the intent of the communication was understood.
We’ve given examples where aviation accidents have occurred because a person issuing a warning failed to make sure that the target of that communication understood the gravity of the situation. We’ve noted that our use of some medical terminology may be confusing in the OR, particularly in multicultural settings. But, if we can confuse other clinicians with our medical jargon, what do we expect when we use it with patients?
A recent study looked at patient understanding of medical terms we use (Gotlieb 2022). Gotlieb et al. surveyed 215 adults about some common medical phrases may lead to confusion among patients affecting health outcomes.
A 13-question survey with a mix of open-ended and multiple-choice questions assessing jargon understanding of common phrases used in medicine was administered. The full survey and contextual comments can be found in the supplementary materials to the Gotlieb article. Note that some of the questions had been used in previous studies demonstrating that patients may have difficulty understanding some medical jargon. Some questions were “dual” in that one was in jargon, the other in non-jargon. Respondents were asked to indicate if they felt these statements indicated good news, bad news, or they were unsure.
Some examples of the questions are:
“We are halfway through your chemotherapy treatment and your tumor is progressing.”
“Your urine tests are back and there were bugs in your urine.”
“You will need to be NPO at 8 am.”
“You are to have nothing by mouth after 4 pm.”
“Your nodes are positive.”
“The findings on the X-ray were quite impressive.”
“I am concerned the patient has an occult infection.”
“Have you been febrile?”
Most respondents (96%) knew that negative cancer screening results meant they did not have cancer. However, fewer respondents knew that “your tumor is progressing” was bad news (79%) or that positive nodes meant their cancer had spread (67%).
Significantly more respondents correctly interpreted the phrase nothing by mouth compared with the use of the acronym NPO (75% vs 11%), respectively. The authors suggest we should actually be using the phrase “You should not have anything to eat or drink”, which is more in keeping with everyday language where “by mouth” is not commonly used.
98% correctly understood “blood test shows no infection”, but only 87% understood the jargon phrase “your blood culture was negative”.
Interestingly, only 41% of respondents correctly interpreted “neuro exam is grossly intact” as good news. The authors speculated this might have been because the word “gross” more often means “unpleasant” than “in general” in common usage.
Few respondents accurately understood the questions that required a free-text response. Only 29% correctly interpreted “bugs in the urine” as intending to convey a urinary tract infection, 9% knew what febrile meant, and 2% of respondents understood the phrase “occult infection”.
The authors did look at factors like age, gender, and educational level but did not come to any firm conclusions about the impact of these on understanding of many of the jargon terms.
The bottom line is that we need to be very careful with the medical terminology we use with our patients and avoid medical jargon where possible. More importantly, we need to make sure our patients clearly understand what we are saying. Asking them, in a non-condescending manner, what they understood from our communication is both appropriate and necessary. The problem is even more serious and complicated when we communicate with them regarding medications and dosages, as highlighted in many of our columns on “numeracy”.
Some of our other columns on health literacy and numeracy:
June 2012 “Parents' Math Ability Matters”
May 7, 2013 “Drug Errors in the Home”
November 2014 “Out-of-Hospital Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
August 2017 “More on Pediatric Dosing Errors”
References:
Gotlieb R, Praska C, Hendrickson MA, et al. Accuracy in Patient Understanding of Common Medical Phrases. JAMA Netw Open 2022; 5(11): e2242972
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