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April 1, 2008
Pennsylvania PSA's FMEA on Telemetry Alarm Interventions
When we look at our root cause analyses, we usually come up with the big three: (1) communication problems (2) failure to buck the authority gradient and (3) problems related to alarms. And when we are asked where to focus FMEA (Failure Mode and Effects Analysis) activities, we always mention situations where alarms are in use.
This month, the Pennsylvania Patient Safety Authority addresses both in a patient safety advisory supplement Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis. They analyzed data on alarm-related incidents from the Pennsylvania Patient Safety Reporting System, then narrowed their focus to responses to alarm interventions related to telemetry so that they could reasonably perform a FMEA. They utilized the FMEA format recommended by Joint Commission.
Their multidisciplinary FMEA team did a great job flowcharting the alarm intervention process and identified 29 steps involved in the telemetry monitoring process. They then brainstormed to identify as many possible failure modes they could think of, prioritized the identified failure modes, and identified root causes for each of those failure modes. They then developed mitigation strategies for each and sought to redesign the processes where feasible. Because they are not a healthcare facility, they could not complete the FMEA process, which would require analyzing, testing, implementing and monitoring the redesigned process. That, of course, is extremely important because, no matter how meticulously we consider the possibility of unintended consequences, surprises often bite back.
Their risk priority rating scale assigned numerical equivalents for probability of occurrence, detectability, and severity and they multiplied these these 3 scores for each identified failure mode to establish priorities for developing mitigation strategies. An arbitrary cut-off score was established but they were careful to point out that not all potential failure modes nicely fit a numerical rating scheme so they allowed for circumstances where clinical and technical staff identified other practical considerations based on their experience.
We dont want to distract you from actually going to their site and actually reading this thorough and thoughtfully done FMEA so we wont give you all their recommendations here. However, they provide excellent recommendations regarding patient identification, optimal display location, ensuring the power source of the telemetry receivers, protocols for when monitoring is temporarily suspended or on standby (eg. during transport or while electrodes are being manipulated), protocols for alarm volume levels, electrode placements and inspection and maintenance, making alarm parameters appropriate to both the individual patient and the setting, and protocols for responding to all alarms (whether low- or high-priority alarms) including establishment of a tiered backup response system. They also point out a very important question easily overlooked in a FMEA is telemetry monitoring indicated in this patient at all?.
We are hard pressed to add much to their solid recommendations but do have one important recommendation. Our July 19, 2007 Patient Safety Tip of the Week Unintended Consequences of Technological Solutons noted an adverse outcome related to transposition of telemetry receivers that were placed on two patients at about the same time. When the telemetry alarm-related incidents from the Pennsylvania Patient Safety Reporting System were analyzed, patient misidentification was one of the root causes seen fairly frequently, though it was not clear if any replicated the circumstances in the case above. We think it is extremely important that a forcing function or constraint be put in place that would preclude a nurse or technician from signing out two remote telemetry receivers at the same time. That forcing function or constraint should require that the appropriate communication and hookup to the telemetry unit occur for the first patient before the same nurse/technician could sign out a second receiver. Would that forcing function/constraint likely produce unintended consequences? For instance, what if there are two patients who emergently need telemetry monitoring? In such circumstance, both those patients would deserve one-to-one nursing care so each should have one nurse sign out one unit. And an alternative strategy would be to have a bar coding system in place whereby the patient identification is electronically communicated to the telemetry system.
As usual, the Pennsylvania Patient Safety Authority has done another excellent job of not only addressing and important, practical problem-prone area but also providing a model that healthcare organizations may look to in doing their own FMEA on any patient safety problem area.
References:
Pennsylvania Patient Safety Authority. Patient Safety Advisory supplement Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis. March 2008
http://www.psa.state.pa.us/psa/lib/psa/advisories/v5n1march_2008/mar_2008_medical_telemetry_fmea_supplementary_review.pdf
Print Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
April 8, 2008
Oxygen as a Medication
In our December 2007 Whats New in the Patient Safety World column we speculated that one of the contributing factors to the occurrence of 1000-fold heparin overdoses may be that heparin flush is often not looked upon as a medication. The same can be said for another substance that should be considered a medication oxygen.
Think about it its a chemical given for specific indications, in a specific dose, via a specific route, for an intended duration. Its use needs to be monitored using clinical and laboratory parameters. Its effects are influenced by existing comorbidities affecting specific organ systems. It has both beneficial effects and potentially harmful effects. Sure sounds like a drug to us!
But oxygen therapy seldom gets the same degree of respect that therapy with other medications gets. Numerous surveys or audits (eg. Boyle 2006) in acute hospitals have revealed that there is often no formal prescription for oxygen therapy and, when there is, the prescription is often inadequate or inappropriate.
While oxygen is obviously very helpful or lifesaving in many circumstances, it does have potential adverse effects as well. Several of our previous columns have focused on nonclinical adverse consequences such as surgical fires or neonatal nursery fires and the role of oxygen in fires. And weve talked about oxygen canisters becoming potentially lethal projectiles in MRI suites. And oxygen has been involved in various ways in cases of tubing misconnections. But there are also potential clinical physiological adverse consequences of oxygen therapy. Obviously in the newborn, hyperoxygenation is associated with the risk of retinopathy of prematurity and potential pulmonary complications. And in the patient with COPD, precipitation of hypercapnia and respiratory depression is a well-known potential complication of oxygen therapy.
Perhaps the most important consideration in oxygen therapy is the order for it. Much like our discussion on inappropriate use of Foley catheters, oxygen therapy seems to have a way of simply popping up on patients in the hospital. It often gets started in the ER, or the post-op recovery room, or other location without adequate documentation of the reasons for its use. It is thus critical that an appropriate order for oxygen always be written (or otherwise entered entered into a CPOE system). That order should include an indication for the oxygen therapy. Each hospital should go through the exercise of establishing a list of the indications for oxygen use. This is not just of practical value it may have educational value as well. For years, those of us who are neurologists commonly began stroke patients routinely on oxygen therapy. In fact, a stroke by itself is not an appropriate indication for oxygen therapy. A study (Pancioli 2002) looked at oxygen utilization on an inpatient stroke population and found that only 45.6% of days of oxygen use were justified by evidence-based criteria they developed.
The order should also include the desired oxygen concentration or flow rate, method of delivery (eg. mask, nasal prongs, etc.), duration of therapy, and the method of monitoring the effectiveness or potential adverse effects of therapy (such as pulse oximetry or arterial blood gases). Because the order may be somewhat complex, some organizations (see Dodd 2000) have developed an oxygen prescription chart or other formal preprinted order set. All the complexities of the oxygen therapy order can also be captured more completely by using a CPOE system.
Compliance with orders for oxygen therapy should also be assessed. How many times have you gone into a patient room and seen the nasal prongs hanging down on his/her neck or being worn on his/her forehead like a sweatband or bandana!
Monitoring the effectiveness of oxygen therapy is usually accomplished noninvasively by pulse oximetry. However, remember that this only measures oxygen saturation and does not provide any assessment of the CO2 and pH status. Youd be surprised how often COPD patients who even have a history of hypercapnia fail to be adequately monitored for hypercapnia. Though hypercapnia may be looked for in other ways (eg. capnography), most often we still look to arterial blood gases before and after initiation of oxygen therapy as the best measure of CO2 status.
The duration of oxygen therapy is often difficult to predict or estimate. Just as each facility should establish criteria for use of oxygen, each facility should develop criteria for cessation of oxygen therapy.
Problems maintaining adequate oxygenation are particularly a problem during transport of patients (within or outside of facilities). The Pennsylvania Patient Safety Authority highlighted this issue in a Patient Safety Advisory in 2005 Continuity of Oxygen Therapy During Intrahospital Transport. They reviewed numerous reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) and looked at failure modes in the many steps involved in maintaining adequate oxygen therapy during transport. They noted that oxygen therapy has been reported to be interrupted in as many as 55% of transports. Failure modes indentified included: failure to treat with oxygen when ordered, failure to initiate flow from the oxygen source, failure to connect the oxygen tubing to the source, failure to place the oxygen delivery device on the patient, and failure to anticipate the oxygen demand and provide an adequate supply throughout the transport.
They suggested standardization of procedures for transport, a formalized hand-off, and clarification of responsibilities for individuals involved. They provided examples from two facilities that addressed these issues. One facility developed a formal communication tool that included details such as the oxygen delivery device, flow rate, PSI, and minutes of oxygen available in the cylinder. The latter is especially important because the sorts of delays that are common when patients are transported away from their rooms (eg. to physical therapy or radiology) make running out of oxygen in the cylinder particularly likely. The above advisory includes a nice table for estimating the amount of oxygen left in the cylinder. They also stress, however, the need to maintain stores of strategically placed oxygen sources throughout the facility and a procedure to ensure that those sources are full and functional. Appropriate education and training of all personnel involved in transports is obviously important.
They include the mnemonic START from Harborview Medical Center in Seattle to help staff remember important steps involved:
Supply adequate oxygen for the trip
Turn on the oxygen cylinder
Apply the cannula or mask to the patient
Rate as ordered and verified
Trace the connections from the patient to the oxygen source
Mark Daly at the McGill University Health Centre led a project called O2 Ticket to Ride that included a two-sided form to be utilized for all transports to ensure adequacy of oxygen therapy. One side had places for documentation of key items such as noted above. The other side had a chart for estimating how long the oxygen should last.
We like the concept of a structured hand-off with a formal communication tool for transport. Many of the same issues that arise for oxygen therapy may apply to other modalities during transport (eg. IV fluids, other medications) and could be addressed in such a tool.
As you implement a plan for management of oxygen therapy, be sure to consider potential unintended consequences. Untreated or undertreated hypoxemia is likely to be a much more frequent cause of patient harm than some of the rarer adverse effects due to oxygen therapy itself.
Implement a good strategy for managing the drug oxygen and you will also make your CFO happy. The Pancioli study noted above identified potentially substantial financial savings if oxygen were only used for those stroke patients meeting appropriate criteria for use.
(For discussion of other oxygen cylinder-related adverse events see Gosbee 2002 and medical gas mix-ups see the FDA Patient Safety News 2002.)
Update: See also our June 10, 2008 Patient Safety Tip of the Week Monitoring the Postoperative COPD Patient and our January 27, 2009 Patient Safety Tip of the Week Oxygen Therapy: Everything You Wanted to Know and More!.
References:
Boyle M, Wong J. Prescribing oxygen therapy. An audit of oxygen prescribing practices on medical wards at North Shore Hospital, Auckland, New Zealand.
Journal of the New Zealand Medical Association 2006; 119: http://www.nzma.org.nz/journal/119-1238/2080/
Pancioli AM, Bullard MJ, Grulee ME, Jauch EC, Perkis DF. Supplemental Oxygen Use in Ischemic Stroke Patients. Does Utilization Correspond to Need for Oxygen Therapy?
Arch Intern Med.2002;162:49-52. http://archinte.ama-assn.org/cgi/content/full/162/1/49
Dodd ME, Kellet F, Davis A, Simpson JCG, Webb AK, Haworth CS, Niven R McL.Audit of oxygen prescribing before and after the introduction of a prescription chart. BMJ 2000;321:864-865 http://www.bmj.com/cgi/content/full/321/7265/864?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=dodd&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
Pennsylvania Patient Safety Authority. Patient Safety Advisory.
Continuity of Oxygen Therapy During Intrahospital Transport. September 2005.
Canadian Patient Safety Institute. McGill University Health Centre project: O2 Ticket to Ride. http://www.patientsafetyinstitute.ca/Canadian_Profiles/Mark_Daly.html
Gosbee J, DeRosier JM. Oxygen (Compressed Gas) Cylinder Hazard Summary. VA National Center for Patient Safety. July 2002. http://www.va.gov/ncps/SafetyTopics/O2Cylinder.html
FDA Patient Safety News. Preventing Deaths and Serious Injuries From Medical Gas Mix-Ups. February 2002. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/printer.cfm?id=114
Print Oxygen as a Medication
April 15, 2008
Computerizing Trigger Tools
This months issue of the journal Pediatrics has an article (Takata 2008) on adverse drug events in pediatric patients that has received considerable media attention. It demonstrated that adverse drug events occur much more frequently in this patient population than previously published. It also was one factor that led Joint Commission to publish a new Sentinel Event Alert on pediatric medication errors. Takata and colleagues modified the IHI Trigger Tool for Measuring ADEs to apply to the pediatric population. They then studied its use in 12 childrens hospitals and found a rate of 11.1 ADEs per 100 patients, a frequency about 5 times higher than typically reported in studies using other methods of detection in the pediatric population. They found that 22% of the identified ADEs were potentially preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively.
The trigger tool they developed was obviously very effective in identifying ADEs. Less than 4% of the ADEs they identified by use of the trigger tool had been identified through the usual occurrence reporting systems at the participating hospitals.
We do endorse the use of trigger tools as part of your quality improvent/patient safety programs but we need to move our thinking to another level. Does it really help us to know that 17.8% of the ADEs consisted of pruritis after exposure to a drug to which the patient had no previously known allergy? Not likely. (It could help if the drug given was one to which the patient had a previously known allergy or if the drug had been given without an appropriate indication. Also it would be useful be sure that the patients allergy list was immediately updated so that the patient does not get the offending drug a second time.) But the chance that quality improvement will occur after follow up on many such cases is small and it still takes at least 20 minutes on most of the chart reviews. So the real focus needs to be on preventable ADEs.
The real value of the Takata paper on use of a trigger tool for identifying adverse drug events is the potential for developing real-time triggers that help us identify such ADEs before harm actually comes to the patient or at least early enough so that immediate interventions can at least mitigate any harm. Thats where we should be focusing our energies.
Trigger tools typically rely on flags developed from information coming from pharmacy or laboratory data sources. Many of the triggers in the IHI trigger tools can be used to identify things that potentially need intervention in real time. For example, a rising serum creatinine should both raise the alert that a potential nephrotoxic agent may need to be stopped or that dosage regimens for renally-excreted drugs may need to be adjusted. Its easy to think of multiple potential possible actions in response to changes in serum sodium, potassium, glucose, hemoglobin, white blood count, platelet count, PT, PTT, INR, etc. Prescription of an anti-diarrheal agent could alert staff to consider the possibility a patient may have developed a C. difficile infection. Prescription of a hi-alert medication (eg. narcotic) or a rescue medication (eg. flumazenil) might also identify patients needing closer attention.
We are all wary as we develop and refine our CPOE (computerized physician order entry) systems that bombarding physicians with too many alerts can be counterproductive. But many of the alerts can be directed to other staff (pharmacy, nursing, etc.). Would it not be more productive to have a QI staff nurse spending 20 minutes identifying a potential preventable complication or mitigating it early rather than doing retrospective chart review? Of course, we cant answer those questions conclusively until we have developed and validated a set of real-time triggers but it sure makes sense to move as much of the process to real time as possible.
We previously mentioned the study done at Northwestern (Szekendi 2006) that utilized such an active electronic trigger tool to identify potential adverse events early (while patients were still hospitalized). They developed such a system using certain abnormal laboratory results and pharmacy data as triggers and demonstrated such a system can identify many adverse events that might have otherwise gone unreported. In addition, it has the more important feature of being able to identify issues in real-time or near-real-time. They gave some specific examples of how the system actually led to interventions that prevented or mitigated harm.
A further advantage of a real-time surveillance system noted in the Szekendi study is that the investigators had the opportunity to speak directly to caregivers who were often able to provide critical information or context about the the case that would not ordinarily be available during retrospective chart review.
Triggers are generally positive results, events or occurrences. But equally important are the negative ones, i.e. the absence of something that is expected. For instance, the lack of a digoxin level within a certain time frame after a change in digoxin dosing, particularly in a patient with renal impairment, should serve as a red flag. And obviously, the lack of an evidence-based intervention (eg. no beta blocker in a patient with a recent MI) should be flagged for intervention or at least investigation.
While the lack of full integration of electronic data systems currently limits trigger tools and active surveillance systems to a limited set of potential adverse events, future advances will likely expand our ability to identify early a larger number of potential adverse events. Hospitals should prioritize events based on their quality improvement/patient safety initiatives and goals, regulatory considerations, and even financial considerations (since almost every adverse event in a hospitalized patient has financial as well as human consequences). It could be a great tool for improving your hi-alert medication program (eg. anticoagulants, narcotics, sedating agents, insulin, neuromuscular blocking agents, etc.). One group (Hartis 2005) demonstrated use of specific triggers to detect and improve warfarin-related adverse events. Itcould also be used to identify potential look-alike/sound-alike (LASA) medication errors. It could be used to flag circumstances where a patients fall risk or DVT risk or even decubitus risk has increased because of events occurring subsequent to admission. It should be noted that such systems are also clearly of potential utility in meeting goals in various pay-for-performance programs.
More and more hospital IT systems are now incorporating electronic medical records and many are including test-based reports (radiology reports, EKG reports, etc.). Some are even mandating that all history & physicals, admission and discharge summaries, consults, and progress notes be entered electronically. The capability of performing text searches and use of techniques such as fuzzy logic have the potential to dramatically expand the data sources that could be used in trigger tools and real-time electronic surveillance systems.
Trigger tools have a place today in your patient safety programs but clearly the wave of the future will be in electronic trigger tools or real-time electronic surveillance programs that integrate rules-based alerts and reminders into your CPOE systems.
By the way, that recent Joint Commission Sentinel Event Alert on pediatric medication errors discusses many of the reasons children and infants may be more prone to medication errors and has many excellent recommendations on things your organization can and should be doing to prevent adverse events related to medication errors. And for those interested in another pediatric trigger tool, see some of the fine work done on the Canadian Paediatric Trigger Tool (Matlow 2005 and Matlow 2007).
References:
Takata, GS, et al: Development, Testing, and Findings of a Pediatric-Focused Trigger Tool to Identify Medication-Related Harm in US Childrens Hospitals. Pediatrics 2008; 121:e927-3935. http://pediatrics.aappublications.org/cgi/content/full/121/4/e927
Joint Commission. Sentinel Event Alert. Preventing pediatric medication errors. Issue 39, April 11, 2008 http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_39.htm
Institute for Healthcare Improvement. Trigger Tool for Measuring Adverse Drug Events.
Szekendi, M K; Sullivan, C; Bobb, A; Feinglass, J; Rooney, D; Barnard, C; Noskin, G A Active surveillance using electronic triggers to detect adverse events in hospitalized patients. Quality & Safety in Health Care 2006; 15(3):184-190 http://qshc.bmj.com/cgi/content/abstract/15/3/184?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Szekendi&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT
Hartis C, Gum MO.; Lederer JW. Use of specific indicators to detect warfarin-related adverse events. American Journal of Health-System Pharmacy 2005; 62(16):1683-1688 http://pt.wkhealth.com/pt/re/ajhp/abstract.00043627-200508150-00010.htm;jsessionid=LDRKjc1KwHJgChNhsvd0LlVyhPhlVsQTth1Yw5cJnwknPTGQr6Vg!509222201!181195629!8091!-1
Matlow A, Flintoft V, Orrbine E, Brady-Fryer B, Cronin CMG, Nijssen-Jordan C, Fleming M, Hiltz MA, Lahey M, Zimmerman M, Baker GR. The Development of the Canadian Paediatric Trigger Tool for Identifying Potential Adverse Events. Healthcare Quarterly 2005;8(Sp):90-93 http://www.longwoods.com/product.php?printable=Y&productid=17671
Matlow A, Cronin G for the CAPHC Paediatric Trigger Tool Research Group.
Reducing Harm in Paediatric Care: Learning about Adverse Events using a Validated Canadian Paediatric Trigger Tool. Presentation at the CAPHC annual conference. Montreal, October 14, 2007
Print Computerizing Trigger Tools
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
Beginning October 1, 2008, Medicare will no longer pay the hospital at a higher rate for eight conditions originally announced in a final rule last year or any conditions added to the list, if they were acquired during the hospital stay. The first eight hospital-acquired conditions (HACs) were:
CMS is proposing to expand the list of conditionsto include:
Comments on the proposed rule will be accepted by CMS through June 13, 2008 a final rule is expected on or before August 1, 2008.
The proposed changes are contained in a 1205-page document CMS-1390-P that is not easy reading! However, it does contain useful information about the conditions selected. CMS does utilize specific criteria in the process of selecting candidates as hospital acquired conditions to be included on the list. They must be of either high cost or high volume or both. They must have an ICD-9-CM diagnosis code that clearly identifies them. And there must be evidence in the literature that the complication is reasonably preventable through application of evidence-based guidelines. The document includes tables that provide links to at least some of the evidence base for preventability of each of the proposed conditions.
We anticipate that at least 7 of the proposed 9 additional HACs will be in that final rule. We suspect that the comments submitted may likely lead to removal of delirium and Legionnaires disease from the list.
The problem with delirium is not that its not important to maintain surveillance for delirum but rather in what the evidence base says about interventions. We discussed delirium briefly in our March 4, 2008 Patient Safety Tip of the Week Housestaff Awareness of Risks for Hazards of Hospitalization. We noted that if the Hazards of Hospitalization Questionnaire tool developed by the authors (Fernandez 2008) can be validated in several settings or populations, it has tremendous potential to help us prevent complications such as delirium. Not only is delirium associated with increased morbidity and mortality, but it is also associated with prolonged lengths of stay and excess costs (Leslie et al. 2008). At least 2 studies have demonstrated that multifactorial interventions targeted at elderly inpatients at risk for delirium may shorten hospital length of stay, reduce duration of delirium, and reduce mortality (Lundstrom et al. 2005; Naughton et al 2005). The Lundstrom study showed that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients. The Naughton study showed that a multifactorial intervention designed to reduce delirium in older adults was associated with improved psychotropic medication use, less delirium, and hospital savings. So there does appear to be some evidence that such programs make sense from quality, patient safety, and financial perspectives. However, the interventions are not likely to significantly reduce the number of patients identified with delirium. In fact, a good tool might actually increase the number identified. There are also many factors that are truly not under control of the hospital and staff that may precipitate delirium. So our feeling is that hospitals should not be penalized unfairly for the occurrence of delirium.
The issue with Legionnaires disease is the problem of attribution to the hospital or the community. A clearcut outbreak in a hospital that can be traced to problems with a pipe system, etc. certainly should merit no pay. The problem is more likely to arise with isolated cases of Legionnaires, which will probably be more common in the long run. In those cases, it may be very difficult to determine whether the patient was exposed prior to or after admission to the hospital. We think that CMS and the hospitals would have a difficult time adjudicating such cases.
So what should hospitals be doing in the interim? Our November 2007 Whats New in the Patient Safety World column pointed out an excellent paper by ECRI Institute on how to get ready for the CMS final rule on Hospital-Acquired conditions. It gives good recommendations on putting together a multidisciplinary team to get ready for this. There is also a video and podcast available. Now, more than ever, hospitals need to prevent costly complications because they will bear the full burden for most of those excess costs. And for the newly added conditions, youll want to make sure you have programs such as the IHI VAP Bundle, and the Peter Pronovost-like checklists to help prevent central-line associated infections, and the Surgical Care Improvement Project (SCIP) bundle, a good system for determining DVT risk and implementing appropriate prophylaxis, fall and decubitus risk assessments, a Foley catheter use reduction program, and a good overall infection control plan. Make good use of standard order sets, trigger tools, and CPOE with clinical decision support. We also expect to see more proceduralists working at hospitals to reduce complications such as pneumothoraces.
References:
CMS Office of Public Affairs. CMS PROPOSES TO EXPAND QUALITY PROGRAM FOR HOSPITAL INPATIENT SERVICES IN FY 2009.Monday, April 14, 2008. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3041&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&srchOpt=0&srchData=&keywordType=All&chkNewsType=1,+2,+3,+4,+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date
Centers for Medicare & Medicaid Services. [CMS-1390-P]. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians. http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-P.pdf
Fernandez HM, Callahan KE, Likourezos A, Leipzig RM. House Staff Member Awareness of Older Inpatients' Risks for Hazards of Hospitalization. Arch Intern Med.2008;168(4):390-396 http://archinte.ama-assn.org/cgi/content/abstract/168/4/390
Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-Year Health Care Costs Associated With Delirium in the Elderly Population. Arch Intern Med 2008; 168(1): 27-32. http://archinte.ama-assn.org/cgi/content/abstract/168/1/27
Naughton BJ, Saltzman S, Ramadan F, Chadha N, Priore R, Mylotte JM. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc. 2005; 53(1):1823 http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2005.53005.x?prevSearch=allfield:(naughton)
Lundstrm M, Edlund A, Karlsson S, Brnnstrm B, Bucht G, Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc. 2005; 53(4): 622628 http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2005.53210.x?prevSearch=allfield:(Lundstrom)
Print CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 29, 2008
ASA Practice Advisory on Operating Room Fires
Weve talked a lot in the last 6 months about fires in hospitals. We had an extensive discussion in our December 7, 2007 Patient Safety Tip of the Week on Surgical Fires, citing all the excellent work done by ECRI on surgical fires. And our January 29, 2008 Patient Safety Tip of the Week Thoughts on the Recent Neonatal Nursery Fire discussed a fire in a neonatal nursery incubator in Minnesota and the ongoing investigation into the causes, with further cases discussed in the April 2008 Whats New in the Patient Safety World column.
Now the American Society of Anesthesiologists has issued a timely release of a Practice Advisory for the Prevention and Management of Operating Room Fires. While it reiterates many of the important principles noted in our previous discussions, there are many good new recommendations that every facility should consider.
It stresses that all anesthesiologists (the intended audience, though it obviously should apply to everyone who works in an operating room or other facility area at risk for fires) should have fire safety education, specifically for OR fires, with an emphasis on the reisk created by an oxidizer-enriched atmosphere. OR fire drills should take place with the entire OR team. Very importantly, the advisory recommends that for each case, the OR team should formally (1) determine whether or not a high-risk situation exists and (2) have team discussion about strategy for prevention and management of a fire. And a protocol for prevention and management of fires should be placed visibly in each location where surgery/procedures might be done, along with all appropriate equipment for managing a fire. Each member of the team should be assigned a task and understand they should perform that task immediately without waiting for other team members to act. (Once they have completed their task, they can help other team members with other tasks). Though there is no evidence base to confirm that such a pre-case team discussion actually prevents or helps manage fires, its certainly good common sense. For those of you who like checklists, its a good item to add to your preoperative checklist.
The discussion on prevention of fires is excellent, with many practical tips. They discuss replacing oxygen with compressed air or discontinuing supplemental oxygen for a period of time (as tolerated and monitored by pulse oximetry). They discuss proper configuration of surgical drapes to avoid accumulation of oxygen and stress adequate drying time when alcohol-based skin preps are used. And sponges, gauze or other cottonoids used should be moistened when being used near an ignition source or near an oxygen-enriched area such as the airway. Scavenging the operating field with suction may help avoid buildup of oxygen (or nitrous oxide).
They discuss use of laser-resistant tracheal tubes (matching the tube type to the laser type) and note that the tracheal tube cuff should be filled with saline rather than air. The saline could also be tinted with methylene blue to help identify laser punctures. They also discuss the type of oxygen delivery system that should be used, based on the required depth of sedation and oxygen dependence.
Coordination between the anesthesiologist and surgeon are critical when it comes to using lasers, electrocautery tools, electrosurgical tools, or other potential sources of ignition. The surgeon should give adequate notice that he/she is about to use such a device and then adequate time should be allowed to elapse to allow the anesthesiologist to take steps to minimize the oxygen in the area.
Their discussion on management of an actual fire is a good one. They emphasize early recognition and that the early signs of a fire may not just be a flame or flash but might include unusual sounds (eg. pop, snap, or foomp), odors, smoke, heat, unexpected movement of the drapes or patient, or discoloration of the drapes or breathing apparatus. When a fire is determined, the fire should immediately be announced, the procedure halted, and fire management tasks should be begun. Each team member should do their assigned task as quickly as possible, not waiting if another team member has not been able to do their task in a predetermined order. The specific tasks are outlined in the document and depend on whether the fire is in the airway or breathing circuit or elsewhere on the patient. They discuss assessment and management of the patient after a fire and discuss more general fire responses as well.
The advisory is very well-referenced and levels of evidence are graded. They do provide a nice algorithm on operating room fires. It can be used as an educational tool and as part of the preoperative procedure, but it does not look like it would be of much use emergently during a fire.
This is another excellent tool. Well-coordinated teamwork is critical in the education about, preparation for, planning for and response to surgical fires.
References:
American Society of Anesthesiologists Task Force on Operating Room Fires. Practice Advisory for the Prevention and Management of Operating Room Fires. Anesthesiology 2008; 108: 786-801 http://www.asahq.org/publicationsAndServices/orFiresPA.pdf
Previous discussions:
December 7, 2007 Patient Safety Tip of the Week on Surgical Fires
January 29, 2008 Patient Safety Tip of the Week Thoughts on the Recent Neonatal Nursery Fire
April 2008 Whats New in the Patient Safety World column.
Print ASA Practice Advisory on Operating Room Fires
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
Ever tried to convince a friend or family member they need to get a polysomnogram because they have symptoms or signs of possible obstructive sleep apnea (OSA)? Then you know how hard it is! You have to keep nagging at them and many months typically pass before they finally agree to get the study, if they ever agree at all. (Note that it is usually easier to convince a patient who comes to see you because of symptoms that bothered them and could be due to OSA).
But suppose you are an anesthesiologist or surgeon and are preparing a patient for upcoming surgery. Knowing they have OSA would be very helpful in planning their management in the preoperative, operative, and postoperative settings. Most cases of OSA are undiagnosed, yet OSA patients have higher rates of postoperative complications and death. So having a screening tool to identify patients likely to have OSA would be extremely useful. Screening tools currently available are either not validated for a surgical population or are too cumbersome to be used from a practical standpoint in the presurgical evaluation.
Enter the STOP Questionnaire, a screening tool for OSA developed by Frances Chung and colleagues at the University of Toronto and several affiliated Toronto area hospitals. They noted that two of the more widely used screening tools for OSA, the Berlin Questionnaire and the American Society of Anesthesiologists checklist, had not been validated in the surgical population. They looked at the Berlin questions and did factor analysis on patient responses to those questions to derive the four questions below:
S Do you snore loudly?
T Do you often feel tired, fatigued or sleep during daytime?
O Has anyone ever observed you stop breathing during your sleep?
P Do you have or are you being treated for high blood pressure?
They did a pilot study, administering the STOP questionnaire to 596 surgical patients and then inviting them to undergo polysomnography (in-lab). That pilot study showed a sensitivity of 72% and positive predictive value (PPV) of 75% and high level of correlation when the test was administered a second time. They then moved on to a validation study in which the STOP questionnaire was given to almost 3000 patients scheduled for a variety of surgical procedures. 17% of those patients agreed to have polysomnography, though only about half of those actually showed up for the polysomnogram. Using a cutoff apnea/hypopnea index of greater than 5, the sensitivity of the STOP questionnaire was 66%, specificity 60%, PPV 78%, and NPV 44%. Using higher AHI cutoffs (corresponding to more severe degrees of OSA) the sensitivities and PPVs were even higher, reaching a sensitivity of 79% and PPV of 89% at an AHI of greater than 30. When they looked at it in patients with certain other known risk factors for OSA (BMI >35, age>50, neck circumference >40, male gender) they found that the STOP-bang questionnaire had even better sensitivities and PPVs and NPVs, especially for moderate and severe OSA.
The American Society of Anesthesiologists has published Practice guidelines for the perioperative management of patients with obstructive sleep apnea. They stress working with the surgeons to allow enough time to develop a perioperative management plan. Based on the degree of clinical suspicion for OSA and suspected severity, a decision needs to be made as to whether to get formal polysomnography to confirm a diagnosis or to simply proceed and assume OSA based on clinical grounds. Similarly, a decision needs to be made as to whether CPAP should be started prior to the surgery. And it must be decided whether the surgery needs to be done in an inpatient setting or outpatient setting, keeping in mind the postoperative requirements. Since many patients with OSA have difficult airways, the airway should be managed per the ASA Practice Guideline for Management of the Difficult Airway.
OSA patients are especially susceptible to the respiratory depressant and airway effects of sedatives, opiods, and inhaled anesthetics so selection of intraoperative agents is important. Local or regional anesthesia should be considered where appropriate. But when sedation is needed, continuous monitoring is required and CPAP or an oral appliance should be considered. They stress that general anesthesia with a secure airway is probably preferable to deep sedation without a secure airway. They also stress that the patients should be extubated while awake and after verification of full reversal of neuromuscular blockade. Use of a nonsupine position (eg. lateral or semiupright) during extubation and recovery is advised.
In the postoperative period, techniques to reduce or avoid systemic opiods are stressed and it is pointed out that sedative agents like barbiturates and benzodiazepines further increase the risk of respiratory depression or airway obstruction. They discuss monitoring issues and possible need for CPAP or NIPPV and supplemental oxygen. They discuss the various venues where a patient may be recovered, stressing the adequacy of the technological and personnel monitoring capabilities.
And they end with a good discussion of the factors to be considered in the inpatient vs. outpatient decision and a discussion about the criteria for discharge to unmonitored settings.
So the bottom line is that because there are so many potential risks and management considerations for OSA patients before, during and after surgery, it is extremely important to consider the possibility of OSA in each patient contemplating surgery. Use of a screening tool such as STOP or STOP-bang Questionnaires may be a major step toward the goal of rendering surgery safe in such patients.
References:
Chung F, Yegneswaran B, Balaji M, Liao P, Chung S, Vairavanathan S, Islam S, Khajehdehi A, Shapiro CM. STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea. Clinical Investigations. Anesthesiology. 108(5):812-821, May 2008. http://www.anesthesiology.org/pt/re/anes/abstract.00000542-200805000-00008.htm;jsessionid=LP3F46NfyKvvTMzsnkPKh2hJlfKJZCLCMx8N7QqTwPv7WmJQjhdR!-859253161!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search
Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology2006 May;104(5):1081-93. http://www.asahq.org/publicationsAndServices/sleepapnea103105.pdf
Print Preoperative Screening for Obstructive Sleep Apnea
May 13, 2008
Medication Reconciliation: Topical and Compounded Medications
Over-the-counter medications and vitamins, minerals and herbal medications are frequently overlooked at the time of medication reconciliation. However, there is another group of medications also frequently overlooked topical medications. Topical medications, of course, play an important role in management of many medical conditions, particularly ocular and cutaneous ones. But there is a whole subset of topical medications that are of special concern: compounded medications.
It used to be that compounding of medications was used primarily when a patient could not take or could not tolerate a specific medication by the usual route. The active ingredient was then compounded into a preparation that could be administered via an alternative route (eg. cutaneous gel or ointment, suppository, etc.). But the industry has changed significantly and the use of compounded medications has become much more complex.
Many of you remember the scrutiny the compounding industry came under several years ago after several deaths related to high systemic concentrations of local anesthetic agents that were in compounded topical preparations. These were creams containing high doses of topical anesthetic agents like lidocaine, tetracaine, benzocaine, and prilocaine and systemic absorption led to seizures and arrhythmias and at least 2 deaths. Small children, those with pre-existing heart disease, and those with severe liver disease were especially vulnerable. Risk of harm was increased if the cream was applied to large areas of the body, was covered by a bandage or dressing, or was left on the body for long periods.
But the FDA has estimated that at least 1% of all medications dispensed nationwide are compounded. Yet, surprisingly, the FDA has almost no oversight authority for compounded medications and most oversight of compounding is done by state Boards of Pharmacy. The FDA did a limited survey of compounded drugs in 2006 and found that potency ranged from 67.5% to 268.4% of the amount of drug declared in the product labeling.
Even less is known about the absorption and bioavailability of drugs that have been compounded. There is very little in the published literature about pharmacokinetics for many single active drug compounded preparations. On top of this, there are now compounded preparations that may have four or more active ingredients. There is almost no literature on what happens to the absorption, bioavailabilty and pharmacokinetics due to interactions of the various component drugs in a compounded preparation. And there is very little published on the efficacy or safety of such preparations.
Of course there are many topical agents that are approved by the FDA and have good safety records. This includes some topical anesthetics. There are also several analgesic patches approved by the FDA. There is even one FDA-approved topical NSAID (Voltaren Gel) for osteoarthritis pain. That has been demonstrated to be clinically effective and safe in randomized controlled trials involving more than 900 patients. Contrast that to some compounded pain preparations that contain ketamine, gabapentin, clonidine, and amitriptyline all in one gel that are advertised by some compounding pharmacies. Another advertises a combination of ketoprofen, baclofen, gabapentin, and lidocaine. Those preparations have not been tested in good RCTs and almost nothing is known about the systemic absorption of the individual components in these complex preparations. Little is known about their efficacy and their safety. If a patient were to develop allergic-like symptoms on such agents, it would be difficult to know which of the ingredients was responsible.
When you perform medication reconciliation, you need to acknowledge any topical preparation the patient is known to have been taking and then decide whether it should be continued or discontinued and whether the patient should be switched to an alternative agent. One of the biggest problems in the medication reconciliation process is often not knowing the full reasons a particular drug or preparation had been prescribed by another physician. Many of the FDA-approved topical agents may simply be continued in the hospital. Particularly with some of the topical narcotic patches, one must strongly consider that the patient would be at risk of a withdrawal syndrome if the patches were discontinued. In such cases, continuation of the patches or switch to oral equivalents (being careful to use nomograms or other aids to help in the appropriate conversion to an oral equivalent) may be necessary. But it is much more difficult to know what to do with some of the compounded preparations mentioned above, particularly some of the 4-drug combination products. Your hospital pharmacy may not be able to match the compounding that had been done at an outside pharmacy. Often the best course in such cases would be to discontinue those compounded medications but be very vigilant for possible symptoms related to withdrawal of one or more components in those preparations.
Medication reconciliation for topicals is also important in radiology. Our February 19, 2008 Patient Safety Tip of the Week MRI Safety noted that drug patches may become patient safety issues in patients undergoing MRI. That is primarily because some of the patches contain metal or ferromagnetic elements that may overheat during MRI and cause burns. A recent article in Medscape discussed which patches need to be removed prior to MRI and which are safe. That article stresses that communication should take place with the prescribing physician to see whether interruption in that drug therapy would be harmful to the patient. And a pharmacist may help determine whether a removed patch needs to be discared or can be reused by the patient.
References:
US FDA. FDA News. FDA Warns Five Firms to Stop Compounding Topical Anesthetic Creams. December 5, 2006. http://www.fda.gov/bbs/topics/NEWS/2006/NEW01516.html
US FDA. 2006 Limited FDA Survery of Compounded Drug Products. http://www.fda.gov/cder/pharmcomp/survey_2006.htm
First Topical Prescription For Osteoarthritis Pain, Voltaren Gel Receives FDA Approval. Medical News Today. October 23, 2007. http://www.medicalnewstoday.com/articles/86402.php
Hulisz DT. Are Topical Patches Safe During MRI or CT Scans? Medscape. May 2, 2008. http://www.medscape.com/viewarticle/572561
Print Medication Reconciliation: Topical and Compounded Medications
May 20, 2008
CPOE Unintended Consequences - Are Wrong Patient Errors More Common?
But there is one issue wed like to bring up now that seems to have escaped attention in the published literature on unintended consequences of CPOE are wrong patient errors more likely to occur after CPOE implementation? We dont know of any study that has statistics about this but there are many practical considerations that may increase the risk of orders being inadvertently entered on the wrong patient with CPOE.
First and foremost is the fact that with CPOE orders are often being entered remotely, that is not at the patients bedside. We previously cited examples of unintended consequences of remote order entry. An issue of ISMPs newsletter a year ago had an example of a nonventilated patient inadvertently being given a paralytic agent, in part because the ordering physician was entering orders from a remote site and accidentally ordered this for the wrong patient.
One might argue that in the old paper-based system we also often enter orders remotely. We often take a chart from the patient chart rack in the nursing station and enter orders there. Certainly one could pick up the wrong chart and begin writing orders there. But there are several factors that probably make it more likely during CPOE and you need to address them during your CPOE implementation to minimize the risk of this unintended consequence. Below are 5 common scenarios that can lead to entering orders on the wrong patient via CPOE:
Weve seen systems where navigation clicks or scrolling remove these critical identifiers from the screen. You need to ensure that the name and other identifiers remain anchored at the top of every screen of your CPOE system. (And remember to make your identifiers consistent with your Joint Commission-capatible patient identification policy).
The cursor/stylus error
The same error one sees with selecting a drug from a drop-down list obviously can also occur when selecting a patient from a drop-down list. We call this a cursor error when it occurs while using a larger data entry device, and a stylus error when using a PDA-type entry device. There errors are probably more common with the latter devices. There are no quick fixes for these, though thoughtful screen layouts can minimize the risk of these errors.
When searching for a specific patient, the results list may be longer than the current screen. The physician may simply pick the last name on the screen if it looks like the one he/she is looking for, failing to realize that there may be more patients with that name (he/she would have to continue scrolling the list to see them). You need to attempt to prevent your patient searches from splitting patients with like names in any screen window (or otherwise alert the user to scroll because there may be more similar names).
You would be surprised to see how often patients with the same or very similar names may be hospitalized at the same time. Shojania (2003) described a near-miss related to patients having the same last name and noted that a survey on his medical service over a 3-month period showed patients with the same last names on 28% of the days. The problem is even more significant on neonatal units, where multiple births often lead to many patients with the same last name being hospitalized at the same time and medical record numbers being similar except for one digit. Gray et al (2006) found multiple patients with the same last names on 34% of all NICU days during a full calendar year, and similar sounding names on 9.7% of days. When similar-appearing medical records numbers were also included, not a single day occurred where there was no risk for patient misidentification. Both these studies were on relatively small services so one can anticipate that the risks of similar names is much higher when the entire hospitalized patient population is in the database.
Many, if not most, hospitals have developed intranet systems that display useful clinical information on patients before they have implemented CPOE. Particularly with some CPOE systems that have limited integration with other systems, it is not uncommon for a physician to look at information on the older intranet system while trying to input orders into the CPOE system. Since they are two different systems, it is possible to be looking at two different patients in the two systems. You therefore need to ensure that when the physician moves between these two systems the same patient must be visible on each system. That means you need to develop a way to launch the other application and port the patient identification information to the other application.
This occurs when a physician leaves the order entry screen temporarily without logging off and a second physician comes by and leaves orders on a patient (without logging on separately). The first physician then returns to the screen and assumes that he/she is still entering orders on the original patient.
Though wrong patient errors have not shown up on the lists of common unintended consequences of CPOE, that may simply reflect that they are less common than many of the other unintended consequences. However, they have the potential to cause more serious patient harm.
References:
Institute for Safe Medication Practices. Remote CPOE errora situation thats more than remotely possible. ISMP Newsletter. May 31, 2007. http://www.ismp.org/Newsletters/acutecare/articles/20070531.asp
Shojania KG. AHRQ Web M&M Case and Commentary. Patient Mix-Up. February 2003. http://www.webmm.ahrq.gov/case.aspx?caseID=1&searchStr=shojania
Gray JE, Suresh G, Ursprung R, Edwards WH, Nickerson J, Shiono PH, Plsek P, Goldmann DA, Horbar J. Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 2006;117;e43-e47
http://pediatrics.aappublications.org/cgi/reprint/117/1/e43
Print CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May 27, 2008
If You Do RCA's or Design Healthcare Processes...Read Gary Klein's Work
Funnyit seems we always do book reviews on holiday weekends! Well, this one has been sitting on our computer for almost a year now. In our May 29, 2007 Tip of the Week we discussed some of the premises in Malcolm Gladwells book Blink. We noted that many decisions, particularly those made in urgent situations, are the result of rapid cognition rather than more deliberate comparison of all possible options. Much of the research basis for that was developed over many years by the cognitive psychologist, Gary Klein. We have included Kleins book Sources of Power. How People Make Decisions in our patient safety library for a long time but never really gave him and his colleagues their due in one of our columns.
It was Klein who began the work on naturalistic decision making (i.e. how people make decisions in field settings) in the 1980s. The field work consisted of interviews of people who had to make decisions of high stakes under time pressure (though much of his subsequent work showed that the same processes often apply even in the absence of time pressures), often with inadequate information, unclear goals, ambiguity, and dynamic (changing) situations or conditions. Prior to the work of Klein and his colleagues, the classical thinking about decision making was that people would assemble the data then analyze multiple options, assign weight to the important elements of each option, compare them and then choose the most rational one as the final option. Kleins interviews of firefighting captains, military commanders, nurses, etc. showed that in most cases these individuals relied on their previous experience and mental simulation to choose a course of action that was likely to work. That is, they chose a single option rather than comparing multiple options.
Klein and others called this the Recognition-Primed Decision Model. In their interviews they found that these critical decision makers often did not think they had even made any decisions. The terms intuition and gut feeling often appear when discussing such scenarios after the fact. However, Klein is quick to point out that intuition is not, in fact, an inborn trait. Rather, it is based on ones experience and it often takes place at a subconscious level.
In essence, the decision makers usually choose the first workable option, which may not necessarily be the best option. They call upon their recognition of patterns, which in turn is based upon their experience, to rapidly diagnose situations and apply courses of action. They recognize a situation that is typical or at least familiar so that they readily have goals that make sense, see cues that are important, know what to expect next, and know typical ways of responding. That pattern recognition includes not only positive cues in the situation, but also cues that are missing. In fact, Klein asserts that the ability to recognize the missing event as a cue is often what separates experts from novices. Most of this pattern recognition takes place at a subconscious level, so the decision maker cannot often tell us why he/she made that decision.
Part of the process also involves making a mental simulation of how the course of action is likely to play out. This type of decision making does not always result in desired outcomes. Confirmation bias (using evidence that bolsters our decision) and dismissing contradictory or disconfirming evidence may lead us to stick with an initial decision that will lead to undesirable outcomes. Explaining away disconfirming evidence is one of the biggest factors leading to undesired outcomes. And the process may not work when the situation is too complicated. Typically, individuals using the RPD model consider a very limited number of variables. When Klein and colleagues analyzed decision making in a wide variety of settings, they concluded that most decisions are made using the RPD model. And experts are more likely to use this model than are novices.
Kleins work suggests that the experience of an individual is what makes them an expert but that one can help develop that expertise. Experts tend to engage in deliberate practice, obtain feedback, and learn from their mistakes. And in developing that expertise, they rely heavily on use of stories, metaphors and analogues that add meaning to their experiences. They also tend to more readily identify leverage points, where small changes can lead to large changes in outcomes.
Klein also talks about the need for mind reading. He says that often in critical situations, the communication leaves the recipient in the position of having to read the mind of the communicator. He gives an example of a surgeon telling an anesthesiologist to give a drug to lower the blood pressure (without specifically mentioning that low blood pressure is his goal). The anesthesiologists gives that drug, then responds to the lower blood pressure by giving a pressor agent that increases the blood pressure. The surgeon tells him to give more of the original drug. He does and again responds to the lower blood pressure by giving additional pressor agent. And the vicious cycle goes on and on. In the patient safety movement, we of course talk extensively about this scenario in team training and simulation exercises and emphasize the need for hearback and other feedback to indicate that all on the team have clear understanding of the goals and procedures.
So why is all this important to those participating in root cause analyses (RCAs)? We commonly have hindsight bias when we review a case with an untoward outcome. We all have the tendency to say things like why couldnt they see that or why didnt they do this. Understanding the type of subconscious factors involved in decision making in such situations helps put us in the position of the actual participants of the situation. We can then better see what cues or lack of cues led them in the direction they went. That will ultimately help us in better designing our processes to help avoid an untoward outcome in similar situations in the future, which is of course the primary goal of any RCA.
And the same goes for those involved in designing various processes in healthcare. We need to understand how people are likely to think and react in certain situations. Klein readily points out that our efforts to prevent errors often just make it more difficult to diagnose a situation. Sometimes accepting errors but making them more visible is much more important that preventing them. This especially applies where we are using technology in the background to handle errors and anomalies, thereby keeping the active participants in the dark about what is going on. Often they find out about those anomalies only to late to take appropriate corrective action or they take an action that actually magnifies the underlying anomaly.
As an aside, to anyone involved in the patient safety field Kleins discussion on the use of stories is right on target. We readily admit that all the statistics in the world about medical error and patient safety cant convey the same message that a single story can. He points out the key elements of a good story: it is dramatic, empathetic, instructive, and often ends with a surprise. A good story is what sticks in peoples minds and is one they often draw upon in recognizing situations and taking a course of action that has a high likelihood of success.
For anyone involved in quality improvement or patient safety, this is a book that you definitely wont regret reading.
References:
Klein G. Sources of Power. How People Make Decisions. Cambridge: MIT Press (1999)
Print If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
June 3, 2008
UK Advisory on
Chest Tube Insertion
The National Patient Safety Agency of the UK NHS just released a rapid response report on the risks of chest drain insertion along with supporting information. The report was prompted by reports of 12 deaths and 15 cases of serious harm over a three year period. These included cases where heart, lungs, major vessels, trachea, phrenic nerve or liver were punctured with consequent hemorrhage or otherwise injured.
Also, over the years that the NYPORTS system in New York has been tracking serious incidents, chest tube insertion has been one of the most common procedures implicated in wrong site incidents. The institutions timeout/verification/safe site protocol should be followed during chest tube insertion just as if you were performing a procedure in the operating room.
The UK report recommends the clinical team always ask the following questions when contemplating inserting a chest drain:
They provide a search of the literature to identify many of the factors contributing to untoward outcomes from chest tube insertion. Lack of appropriate training and supervision, unfamiliarity with equipment, and lack of understanding of anatomical considerations were common contributing factors.
AHRQ has actually funded production of a DVD that uses video excerpts of 50 actual chest tube insertions and uses a nemonic to help illustrate some of the more common problems:
The DVD is available through the AHRQ website.
Many hospitals are seeing the development of proceduralists to handle procedures which are prone to risk, particularly when done by less experienced staff. Particularly in the era where CMS and other third party payors are beginning to withhold payment in cases with preventable complications, development of proceduralist programs is looking more and more cost effective.
References:
UK NPSA Rapid Response Report: Risks of chest drain insertion. May 15, 2008 http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=11636
UK NPSA. Supporting Information.Rapid Response Report: Risks of chest drain insertion. Reference NPSA/2008/RRR03. Issued: May 2008
http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=11637
Problems and Prevention: Chest Tube Insertion. Patient Safety: Findings in Action. AHRQ Publication
No. 06-P024, September 2006. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/qual/chesttubes.htm
Landro L. To Reduce Risks, Hospitals Enlist 'Proceduralists'. Wall Street Journal
July 11, 2007 http://www.hospitalmedicine.org/AM/TemplateRedirect.cfm?TEMPLATE=/CM/ContentDisplay.cfm&ContentID=13663
Print UK Advisory on Chest Tube Insertion
June 10, 2008
Monitoring the Postoperative COPD Patient
In our April 8, 2008 Patient Safety Tip of the Week Oxygen as a Medication we discussed both the benefits and risks of oxygen therapy. While oxygen is obviously very helpful or lifesaving in many circumstances, it does have potential adverse effects as well. In the patient with COPD, precipitation of hypercapnia is a well-known potential complication of oxygen therapy. In days of old we were taught that oxygen therapy in the COPD patient depressed respiratory drive. However, most now feel that oxygen therapy in the COPD leads to hypercapnia by impaired ability to eliminate CO2 due to increased ventilation/perfusion mismatch.
The problem is nicely illustrated by a March 2008 AHRQ Web M&M case. That was a case of an elderly patient with COPD who developed an exacerbation of COPD with community-acquired pneumonia. On oxygen 4L/min. she developed obtundation due to hypercapnia and respiratory acidosis while her O2 saturation was 98%. That article elegantly makes the case that an overdose of oxygen in that patient led to the untoward event. The author points out that most COPD patients have become quite tolerant of lesser degrees of oxygen saturation and points out that the currently recommended target oxygen tension in exacerbated COPD is about 6065 mm Hg, which is equivalent to a saturation of approximately 90%. He points out that most patients with exacerbations of COPD are adequately oxygenated if the oxygen tension can be maintained above 50 mm Hg, corresponding to an oxygen saturation above about 85%. He states that an about-to-be-published British Thoracic Society Emergency Oxygen Guideline for the United Kingdom will recommend that the saturation should be maintained above 88% in most cases of exacerbated COPD to allow an additional margin of safety but that high-risk patients with prior hypercapnic respiratory failure may be safely managed with an oxygen saturation in the range of 85%.
A scenario we commonly encounter is the COPD patient who undergoes surgery and needs postoperative opioids for pain relief. Those patients are especially at risk for hypercapnia due to both the oxygen effect and the respiratory depressant effect of the opioids. Such patients may be at risk for hypercapnia even if they have not had a prior episode of hypercapnia.
Monitoring the effectiveness of oxygen therapy is usually accomplished noninvasively by pulse oximetry. But this only measures oxygen saturation and does not provide any assessment of the pCO2 and pH status. Youd be surprised how often even COPD patients who have a history of hypercapnia fail to be adequately monitored for hypercapnia.
The gold standard for monitoring nonintubated patients for hypercapnia is still arterial blood gas analysis. However, ABGs are an invasive test and their risk may be further increased in the postop patient because of pharmacologic DVT prophlylaxis.
Therefore, we often need to look at ways to nonivasively monitor such patients. Dont forget that the patients level of arousal/mental status is really a vital sign! It is critical that monitoring the patients level of arousal be built into the monitoring protocols. Our nursing colleagues in the field of pain management have used some practical scales in monitoring patients on PCA pump treatment.
We can learn from our colleagues in the field of pain management. Pasero and McCaffery (2002) discuss risk factors for opioid-induced respiratory depression and keys to monitoring such patients. Infants less than 6 months old, opioid-nave elderly patients, and patients with coexisting conditions such as COPD, sleep apnea, or major organ failure are at increased risk of respiratory depression. In addition, drugs such as intramuscular opioids, muscle relaxants and anxiolytics, benzodiazepines, sedating antihistamines, and some antiemetics may increase the risk for opioid-induced respiratory depression. In their discussion of monitoring, they provide the following very practical sedation scale:
S = Sleep, easy to arouse (acceptable; no action necessary)
1 = Awake and alert (acceptable; no action necessary)
2 = Slightly drowsy, easily arousable (acceptable; no action necessary)
3 = Frequently drowsy, arousable, drifts off to sleep during conversation (unacceptable; decrease opioid dose by 25-50%, add an opioid-sparing analgesic, and monitor the patients level of sedation and respiratory status closely)
4 = Somnolent, minimal or no response to physical stimulation (unacceptable; stop opioid, consider administering naloxone)
But it should be kept in mind that an oversedated patient may respond to physical stimulation by becoming aroused and answering questions and their respiratory rate may improve temporarily as well (Cohen et al 2006). But they fall back into the state of oversedation when the stimulation ceases. Therefore, the level of arousal and rate and depth of respiration should first be assessed by simply observing the patient before stimulation.
Measurement of end-tidal CO2 has been long utilized in intubated patients, but capnography has been gaining interest in multiple settings for non-intubated patients. DArcy (2008) discusses use of capnography to monitor for hypoventilation in patients on PCA. Other studies have documented the utility of capnography in PCA patients (Overdyk 2007) (Maddox 2006), monitored anesthesia care (Soto 2004), and postoperative orthopedic patients at risk for sleep apnea (Hutchison 2008), though the usefulness was often due to the equipments ability to identify apneic periods rather than identifying high end-tidal CO2 levels. Newer methods using isotopes for monitoring for hypercapnia are under investigation (Modak 2007).
Facilities need to establish methods for identifying patients at high risk for respiratory depression when on opioids and implement protocols for monitoring them. Understanding the role of oxygen therapy in the COPD patient and its potential for precipitating hypercapnia and respiratory arrest is an important part of this process. Keep your eyes open for the British Thoracic Society guideline "Emergency Oxygen Use in Adult Patients" expected to be published in Thorax this summer.
Update: See our January 27, 2009 Patient Safety Tip of the Week Oxygen Therapy: Everything You Wanted to Know and More!. This summarizes the British Thoracic Society Guideline Emergency Oxygen Use in Adult Patients that was published in the Journal Thorax in October 2008. It has an excellent section on management of patients at risk for hypercapnic respiratory failure. It does not, at this time, make recommendations about noninvasive monitoring techniques for CO2 retention. It points out that measurement of end-tidal CO2 does not correlate well with arterial pCO2, hence is of limited value in monitoring the COPD patient or other patient at risk for hypercapnic respiratory failure. It does offer optimism that newer devices that noninvasively measure both oxygen saturation and pCO2 are in the research pipeline. They also stress observation for the clinical signs of hypercapnia (vasodilation, bounding pulse, flapping tremor, drowsiness, confusion and coma).
ODriscoll BR, Howard LS, Davison AG and the British Thoracic Society. Emergency Oxygen Guideline Group. BTS Guideline Emergency Oxygen Use in Adult Patients. Thorax 2008; 63 (suppl. VI): 1-68
References:
O'Driscoll BR. AHRQ Web M&M Case & Commentary. Overdose on Oxygen?. March 2008 http://www.webmm.ahrq.gov/case.aspx?caseID=172
Pasero C, McCaffery M. Monitoring Sedation: It's the key to preventing opioid-induced respiratory depression. AmericanJournal of Nursing. 2002; 102(2):67-69
Cohen MR, Weber RJ, Moss J (Institute for Safe Medication Practices). Patient-Controlled Analgesia: Making it Safer for Patients. A continuing education program for pharmacists and nurses. ISMP. April 2006 http://www.ismp.org/profdevelopment/PCAMonograph.pdf
DArcy Yvonne. Keep your patient safe during PCA. Nursing2008 2008; 38: 50-55 http://www.nursingcenter.com/prodev/ce_article.asp?tid=762689
Overdyk FJ, Rickey Carter R, Maddox RR, Callura J, Herrin AE, Craig H
Continuous Oximetry/Capnometry Monitoring Reveals Frequent Desaturation and Bradypnea During Patient-Controlled Analgesia. Anesth Analg 2007; 105: 412-418
http://www.anesthesia-analgesia.org/cgi/content/abstract/105/2/412
Maddox RR, Williams, CK, Oglesby H, Butler B, Colcasure B. Clinical experience with patient-controlled analgesia using continuous respiratory monitoring and a smart infusion system. American Journal of Health-System Pharmacy. 63(2): 157-164, January 15, 2006.
Soto RG, Fu ES, Vila H, Miguel RV. Capnography Accurately Detects Apnea During Monitored Anesthesia Care. Anesth Analg 2004;99:379-382 http://www.anesthesia-analgesia.org/cgi/reprint/99/2/379
Hutchison R, Rodriguez L. Capnography and Respiratory Depression. Am J Nurs 2008 Feb;108(2):35-9 http://www.ncbi.nlm.nih.gov/pubmed/18227667?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/17454270
Print Monitoring the Postoperative COPD Patient
June 17, 2008
Technology Workarounds Defeat Safety Intent
During a Patient Safety Walk Rounds session, we witnessed an interesting but troublesome workaround. A nurse was using a new barcoding system to perform medication administration. The bar code on one unit-dose medication would not scan properly because of a crinkle in the barcode. The nurse was to then manually input the barcode from the package onto the system computer. However, the print on the barcode was too small for her to read. She then prepared to cut and paste the medication number from the computer screen into the manual entry input box. That, of course, would have bypassed the whole patient safety concept of a barcoding system, which is to verify that the medication being given is the same as the one on the computer screen. Simply typing in those same numbers seen on the computer screen would have also bypassed the safety mechanism involved in barcoding. While we intercepted this instance to prevent a potential error, there are undoubtedly many similar workarounds being used with barcoding systems.
Workarounds, or similar intentional violations of a rule or procedure, are very common in healthcare (see our Septemeber 4, 2007 Patient Safety Tip of the Week Workarounds as a Safety Issue). They are usually performed with the best of intentions and are usually an indication of a flawed or poorly designed underlying process or system. In the case at hand, the nurse would have had to go search for a magnifying glass to read the barcode or contact the pharmacy to send up another unit dose. Attaching a magnifying glass (and it would have to be lighted to help during night medication administration) to the barcode scanner would also be a workaround solution. Designing the software to prevent cut and paste would be smart but that wouldnt prevent simply reading the drug number from the computer screen and entering it into the manual entry input box. The only real solution for the root cause here would be to ensure the printed numbers on the barcode label are big enough for someone to read in the event that the barcode becomes unscannable. So, again, this is a system design flaw that needs to be fixed.
We wondered how often this type of barcoding system workaround occurred and whether there were other similar workarounds we needed to watch out for. Fortunately, Ross Koppel (Koppel et al 2008) and his colleagues had just published an article identifying the multiple types of workarounds in barcode systems and their underlying causes.They identified 15 types of workarounds and 31 types of causes for the workarounds in barcoding medication administration systems.
They further classified the types of workarounds into three broader categories. Under omission of process steps they included things like failure to scan patient identification barcode, failure to scan the medication barcode, failure to review any alerts that popped up, failure to perform visual checks, failure to perform double checks for high-risk medications, etc. Under steps performed out of sequence the included things like documenting the medication as administered before they actually administered it or observed the patient take it. The third category unauthorized process steps included things like disabling the audio alarms or removing the scanner from the computer cart (which makes it impossible to hear the alert on the computer). It would also include things like carrying medications for more than one patient at the same time, scanning the same medication package several times when the patient is to receive multiple packages, and scanning patient identification barcodes from places other than on the patient. The latter phenomenon has popped up at many different hospitals and reproductions of the patient ID bracelets are made and attached to things like an RNs clipboard, nurses pockets or belts, the computer-on-wheels, room doorjamb, etc. and then scanning those reproductions rather than the patients actual ID bracelets.
They group the 31 types of causes for workarounds into groups: (1) technology-related causes (2) task-related causes (3) organizational causes (4) patient-related causes and (5) environmental. Their table of the causes is comprehensive and they provide excellent examples of each type of cause. The technology-related causes include not only things like equipment failure but also both negative and postivie attitudes about the barcoding technology (so some distrust it and others put too much reliance on it). Task-related causes include time pressures, emergency cases, etc. Organizational causes include things like poor training, medications without barcodes, barcodes obscured by other stickers, and others. Patient-related causes include circumstances such as patient isolation and environment-related causes include things like loud noises obscuring the auditory alarms. We strongly encourage you to read the full article to see all the observed workarounds and the identified potential causes and their recommendations.
Equally important is the methodology Koppel et al used in their study. They used multiple methods to investigate: (1) direct observation (shadowing) (2) interviews with care providers (3) failure mode and effects analysis (FMEA) (4) attending meetings with staff on the barcoding administration system and (5) review of the barcode system override data log. While we have always been huge advocates for looking for workarounds when we do patient safety walk rounds, we also advocate using multiple methods to identify problems. For example, if we are writing a new rule for an alert or reminder on a CPOE system, we always employ multiple measurements of the use and impact of that alert/reminder. Those measurements should include both objective parameters (eg. number of times triggered, number of overrides, etc.) and subjective parameters (asking physicians what they like or dont like about that particular alert). In addition, we try to measure the impact that alert had on the bigger picture (eg. did it reduce the occurrence of ADEs or nosocomial infections).
The Koppel article is a must-read for anyone using or contemplating a barcoded medication administration system. It also has an excellent bibliography.
Another excellent paper (Cochran et al 2007) reviews both errors prevented by and those caused by barcoded medication administration systems, based on error reports submitted to the MEDMARX database. About 10% of the errors caused by barcoding systems were related to workarounds. The two most common workarounds were scanning the medications at the nursing station instead of bedside or scanning the patient identification from something other than the patients wrist. Of course, there are other cases where the wrong ID bracelet may be placed on a patient such as the near-miss reported by McDonald (McDonald 2006) in which 2 patients were admitted around the same time had their wrist ID bracelets transposed and one of them almost received what could have been a fatal dose of insulin as a result.
There are several good articles on workarounds in general. The December 2005 Advisory from the Pennsylvania Patient Safety Authority has an excellent and practical article on workarounds. That article includes a list of over 70 at-risk behaviors compiled by ISMP relating to medication safety. Many of the at-risk behaviors involve workarounds and apply to multiple activities besides medication safety. The list is a good place to begin your look at potential error-producing behaviors that may be amenable to change. For those interested in some of the more technical and esorteric aspects of workarounds, see the series of articles by Halbesleben and colleagues (Halbesleben et al 2008a, Halbesleben et al 2008b, Vogelsmeier et al 2008).
Workarounds are virtually always a symptom of a flawed system. Hunt them down and you will identify numerous opportunities to improve patient care and avoid untoward outcomes.
References:
Koppel R, Tosha Wetterneck T, Telles JL, Karsh B-T. Workarounds To Barcode Medication Administration Systems: Their Occurrences, Causes, And Threats To Patient Safety. JAMIA 2008; PrePrint: Accepted Article. Published April 24, 2008 as doi:10.1197/jamia.M2616http://www.jamia.org/cgi/reprint/M2616v1
Cochran GL, Jones KJ, Brockman J, Skinner A, Hicks RW. Errors Prevented by and Associated with Bar-Code Medication Administration Systems. Joint Commission Journal on Quality and Patient Safety 2007; 33: 293-301
http://www.jointcommission.org/NR/rdonlyres/6DE55F0B-F81B-4D6B-8CE5-3B18106F813F/0/06Cochran.pdf
McDonald CJ. Computerization Can Create Safety Hazards: A Bar-Coding Near Miss. Ann Intern Med. 2006;144:510-516 http://www.annals.org/cgi/reprint/144/7/510.pdf
Pennsylvania Patient Safety Authority.Workarounds: A Sign of Opportunity Knocking. PA-PSRS Patient Safety AdvisoryVol. 2, No. 4 (Dec. 2005) http://www.psa.state.pa.us/psa/lib/psa/advisories/v2n4december2005/vol_2-4-dec-05-article_g-workarounds.pdf
Halbesleben RB, Rathert C. The role of continuous quality improvement and psychological safety in predicting work-arounds. Health Care Management Review 2008; 33: 134-144
Halbesleben JR, Wakefield DS, Wakefield BJ. Work-arounds in health care settings: Literature review and research agenda. [Review] [54 refs] Health Care Management Review 2008; 33: 2-12
Vogelsmeier AA, Halbesleben JR, Scott-Cawiezell JR. Technology implementation and workarounds in the nursing home. Journal of the American Medical Informatics Association 2008; 15: 114-9
Print Technology Workarounds Defeat Safety Intent
June 24, 2008
Urinary Catheter-Related UTI's: Bladder Bundles
Joint Commission has just released the 2009 National Patient Safety Goals. Major new features or changes include goals on prevention of hospital-associated infections, medication reconciliation, and an updated Universal Protocol. Well be discussing the new and modified NPSGs in our July Whats New in the Patient Safety World column. But this week, our review of two new papers on prevention of catheter-related urinary tract infections led us to a hidden cache of great resources for prevention of catheter related UTIs.
First is a new study on indwelling urinary catheter use in the postoperative period (Wald et al 2008). They looked at data from the National Surgical Infection Prevention Project and found that 86% of patients undergoing major surgery had perioperative indwelling urinary catheters and that in 50% of these the catheter duration was longer than 2 days. The latter group was twice as likely to develop UTIs as those with catheters for less than 2 days. Those associations obviously suggest an opportunity to reduce nosocomial UTIs by early removal of such indwelling catheters.
The second study was a randomized controlled trial of automatic stop orders to reduce inappropriate urinary catheterization in hospitalized patients (Loeb et al 2008). The intervention was successful in reducing the duration of both inappropriate and total urinary catheterization. However, there was no statistically significant reduction in the occurrence of UTIs. Those results are similar to a study (Cornia et al 2003) that demonstrated CPOE could reduce duration of indwelling catherization in hospitalized patients but did not result in statistically significant reduction in the occurrence of UTIs. Sample size may have precluded demonstrating a reduction in the more important outcome of UTIs.
But our search into the references in these papers led us to a collaborative done by the Michigan Health & Hospital Association, the MHA Keystone: Hospital-Associated Infection Initiative: Catheter-Associated UTI (CAUTI) Prevention Bundle [aka Bladder Bundle]. That document includes not only facts about catheter-associated UTIs but also points out many of the other downsides of urinary catheters (discomfort, delayed discharge, concept that the catheter acts as a one point restraint that limits activity and might lead to other complications of inactivity, etc.). It notes that 38% of attending physicians in one study were unaware their patients even had an indwelling catheter (Saint et al 2000). The MHA bundle cites those interventions shown to be effective (aseptic technique at insertion, closed drainage, various drainage bag issues, hand hygiene, avoiding unnecessary catheterization, use of alternatives to indwelling catheters, etc.). They provide a description of the intervention led by a nurse champion and provide tools for baseline and subsequent assessment, catheter reminder and removal prompts, and references on use of portable bladder ultrasound monitoring. If many of these sound familiar, its because Sanjay Saint whose work weve discussed in several of our Patient Safety Tips of the Week did much of his early work in Michigan. Our reference list below also includes many of the good background articles available through the MHA website.
Another good reference are the epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. These discuss the evidence base for catheter insertion, maintenance, and selection of catheter type and include not only which practices have been demonstrated to work but also which ones do not make a difference.
And dont forget our previous columns on urinary catheter-associated UTIs:
May 8, 2007 Tip of the Week Doctor, when do I get this red rubber hose removed?
January 8, 2008 Tip of the Week Urinary Catheter-Associated Infections
April 2008 Whats New in the Patient Safety World column More Neonatal Incubator Fires, More on Nosocomial UTIs, More on 1000-Fold Heparin Overdoses
References:
Joint Commission 2009 National Patient Safety Goals
http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdf
Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling Urinary Catheter Use in the Postoperative Period. Analysis of the National Surgical Infection Prevention Project Data. Arch Surg.2008; 143(6): 551-557 http://archsurg.ama-assn.org/cgi/content/abstract/143/6/551
Loeb M, Hunt D, O'Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008; 23: 816-820 http://www.springerlink.com/content/yu12052813472672/
Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med. 2003; 114(5): 404-7 http://download.scientificcommons.org/337
MHA Keystone: Hospital-Associated Infection Initiative:
Catheter-Associated UTI (CAUTI) Prevention Bundle [aka Bladder Bundle]
Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, Bernstein SJ, Lipsky BA, Hofer TP. Are Physicians Aware Of Which of Their Patients Have Indwelling Urinary Catheters? Am J Med. 2000; 109: 476480 http://www.mha.org/mha/keystone/hai/conferencecalls/010407/Are Physicians Aware Of Which of Their Patients.pdf
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall C, Wilcox MH. epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection (2007) 65S, S1S64 http://www.epic.tvu.ac.uk/PDF Files/epic2/epic2-final.pdf
Wald HL, Epstein AM, Radcliff TA, Kramer AM. Extended Use of Urinary Catheters in Older Surgical Patients: A Patient Safety Problem?. Infection Control & Hospital Epidemiology. 29(2):116-124, February 2008 http://www.journals.uchicago.edu/doi/abs/10.1086/526433?cookieSet=1&journalCode=iche
Nurse Initiated Discontinuance of Urinary Indwelling Catheters
MHA Foley catheter prevalence worksheet
Warren JW. Catheter-associated urinary tract infections. International Journal of Antimicrobial Agents 17 (2001) 299303 http://www.mha.org/mha/keystone/hai/conferencecalls/010407/CAUTI.pdf
Wong ES, Hooton TM. Guideline for Prevention of Catheter-associated
Urinary Tract Infections. CDC February 1981
http://www.mha.org/mha/keystone/hai/conferencecalls/010407/guidelines CAUTI prevention.pdf
Saint S. Enhancing Patient Safety by Translating Nosocomial UTI Research Into Practice (slides) http://www.mha.org/mha/keystone/hai/workshops/041207/Sanjay Saint.ppt
Sanjay Saint, MD, MPH Clinical and economic consequences of nosocomial catheter-related bacteriuria. AJIC Am J Infect Control 2000; 28: 68-75
Gokula RRM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004; 32: 196-9
http://www.mha.org/mha/keystone/hai/conferencecalls/010407/inappropriate foley use.pdf
Maki DG, Tambyah PA. Engineering Out the Risk of
Infection with Urinary Catheters. Emerging Infectious Diseases 2001; Vol. 7, No. 2: 1-6
http://www.mha.org/mha/keystone/hai/conferencecalls/010407/engineering urine cath.pdf
Urinary Catheterization: Insertion, Care and Maintenance of the Indwelling Catheter
Print Urinary Catheter-Related UTIs: Bladder Bundles
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Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
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
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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