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April 2, 2019
Unexpected Events During MRI
We’ve done quite a few columns on patient safety issues related to MRI scanning and safety issue in radiology departments in general (see the list at the end of today’s column). But unexpected events beyond just those related to patient safety may impact patient flow and efficiency within the MRI suite. A recent study of almost 35,000 MRI scans in a large multi-hospital system quantified the unexpected events encountered in patients having MRI scans (Sadigh 2017). The authors found that unanticipated events occurred in 16.7% of all scans.
Rates of unanticipated events for each of the following categories were:
Patient events unrelated to contrast included:
Other patient events unrelated to contrast included issues regarding body habitus, pregnancy, falls, inability to complete the exam, and code called for resuscitation.
The authors found that the rate of overall unanticipated events was significantly higher in university-affiliated sites than at community-affiliated sites (18% vs. 5%), in scans performed in the mixed outpatient/inpatient settings than those strictly outpatient settings (22.3% vs. 12.6%), and in scans performed during weekends/holidays than on business days (21.5% vs. 16.2%). The authors anticipated that patients at university-related sites were likely more complicated, hence more likely to experience unexpected events. However, the magnitude of the difference was quite striking. The higher weekend/holiday rate was largely driven by patient events unrelated to contrast.
Delays in performing MRI are not, per se, patient safety events. But they do become important because such delays lead to time pressures that can subsequently be factors contributing to other events that are true patient safety events. For example, in our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” we noted that a delay in recognizing a patient had claustrophobia and needed sedation led to time pressures that likely contributed to a fatal medication error. (That case involved PET scanning, not MRI scanning, but one can easily see how the same might happen with MRI).
We refer you back to some of our earliest columns on MRI safety and, in particular the work of Emanuel Kanal and Tobias Gilk (see our October 25, 2011 Patient Safety Tip of the Week “Renewed Focus on MRI Safety”).
And, of course, we’ll point out that the majority of adverse events in the MRI suite probably have little to do with MRI imaging itself. In our numerous columns on the radiology suite being a hazardous area (see, for example, our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?”), we’ve pointed out that patients coming for imaging studies often have complex medical problems and are often receiving multiple medications, have multiple IV lines and other catheter connections, and have multiple monitoring needs. The primary caregivers are often not attending the patient in radiology and communication breakdowns are common. Add to that certain features that are more common in the MRI suite: need to isolate the patient in a room, preclusion of certain types of equipment, and the frequent need for sedation.
Pediatric patients, in particular, often need sedation for an MRI scan. We have discussed procedural sedation in children in several columns (see our What’s New in the Patient Safety World columns for August 2016 “Guideline Update for Pediatric Sedation” and or Patient Safety Tips of the Week for January 17, ,2017 “Pediatric MRI Safety” and August 8, 2017 “Sedation for Pediatric MRI Rising”). A very interesting approach to reduce the need for sedation in young children comes from Denmark (Forrest 2018). Researchers developed an app that features animated characters that explain what to expect from the MRI scan on a level suited to the child's age and cognitive ability. It tells the young children (age 4 to 9) what to expect. For example, it lets them know the scan will make loud noise and that they have to hold still. Using the app, they were able to substantially reduce the number of children undergoing sedation for MRI.
New 2019 guidelines for safe provision of anesthesia in magnetic resonance units in the UK (Wilson 2019) have been published. These are outstanding guidelines that include provisions for safety of not only patients but also staff. The supplemental tables include a series of very useful checklists for MRI safety.
They divide MRI hazards into five broad categories:
All patients must be screened for devices and implants that may contraindicate a safe scan. The UK guideline (Wilson 2019) has a checklist for such screening. It also has excellent sections on passive implanted medical devices (eg. vascular access ports, catheters, cardiovascular stents, heart valves, orthopedic, ocular and penile implants, tissue expanders, breasts implants) that may contain metal components that may either heat up during scanning, produce artefact of the image or discomfort for the patient if the implant moves during the MRI scan itself.
The section on implanted cardiac devices is excellent. It notes that most prosthetic heart valves, mechanical or bioprosthetic, and all coronary stents are considered safe in the MR environment at field strength up to 1.5 T and many will be safe up to 3 T. While the presence of a pacemaker or internal defibrillator formerly was considered an absolute contraindication to performing an MRI scan, this is now considered a relative contraindication, as MR conditional pacemakers allow patients to have non‐cardiac MRI scans under controlled conditions. These conditions are always detailed by the device manufacturer. But, in some cases, the pacemaker needs to be turned off and then reprogrammed following the scan, so coordination with the patient’s cardiology team is needed. And, obviously, the patient needs monitoring during the scan. They note that implantable defibrillators are usually a contraindication for MR, but in some cardiac centers scanning is possible, with appropriate monitoring and resuscitation support.
Other devices covered in the guidelines are programmable shunts (for hydrocephalus), neurostimulators and implantable programmable devices, programmable pumps, and even self-implanted devices like RF chips.
The guidelines also have a section dealing with gadolinium, discussing risks and safety issues to be considered when deciding whether use of gadolinium contrast will add important information from the scan.
Acoustic damage is a threat from MRI scanning. The UK guidelines require that all people remaining in the scanner room are provided with MR Safe hearing protection (eg. earplugs, ear defenders or both), noting this is particularly important for anesthetised patients, who are unable to alert the operators to hearing discomfort. Temporary hearing loss may occur with stronger magnets so patients and staff should be warned. For anesthesia personnel, they note a set‐up allowing remote monitoring from the control room is ideal. But, if this is not possible, staff who remain within the examination room must wear ear protection and be aware that the noise may still make communication difficult.
Many of the adverse events affecting patients during MRI could have been prevented by appropriate monitoring. The UK guidelines have a detailed section on equipment and monitoring. They note that most units exclude all unlabeled or MR Unsafe equipment from the examination room, but they do describe unique cases where constraints like physical tethers have been used. They recommend use of fibreoptic pulse oximeters because standard oximeters have been associated with reports of burns caused by induction currents. Similarly, specific MR Safe ECG electrodes are needed to monitor the patient during anesthesia or sedation because of the risk of burns with standard ECG electrodes and leads. They also advise that care should be taken interpreting the ECG trace when the patient is being scanned. They also have specific recommendations regarding both non‐invasive and invasive blood pressure monitoring, capnography, temperature monitoring, and other devices, such as intracranial pressure monitors.
The guidelines, of course, include details about how sedation and/or anesthesia should be provided in the MRI unit. They also have comments on specific situations like pregnancy, pediatrics, patients from ICU’s, and intraoperative MRI.
The guidelines also have sections on layout and design, visibility, access control, personnel and workflow, training and supervision of staff, and emergency procedures. The reference list is extensive and the checklists in the supplemental materials are very useful. These guidelines are a “must read” not only for anesthesiologist and MRI unit staff but for anybody who sends patients for MRI scanning.
There have been other good recent references on MRI safety (Sammet 2016, Cross 2018). Sammet discusses the various MRI zones and the importance of training for anyone that might enter the various zones. Note also that we have recommended you also do training sessions with your local fire and police departments on responding to emergencies in the MRI suite (see our October 21, 2014 Patient Safety Tip of the Week “The Fire Department and Your Hospital”). That last thing you want is a first responder wielding an axe or metallic weapon entering a zone where a magnet is active.
A recent Pennsylvania Patient Safety Advisory (Field 2018) reported on the incidents in Pennsylvania involving over 1100 MRI screening events from 2009 to 2017. The article lists a myriad of medical and nonmedical devices and objects that were brought to MRI suites and discusses what sorts of objects are allowable in the specific MRI zones. More than a quarter of the events involved a device or object brought into the MR scanner room that was not considered safe for MRI. The most common objects or devices involved in MRI screening events were pacemakers (32.3%). 35.2% of events involved external objects, carried in by or attached to the patient or healthcare staff. Of the 1100+ incidents, there were only five serious events (one nonmedical object projectile, one thermal injury from an external medical device, and three malfunctions or displacements of internal medical devices).
Field identified the following factors as contributing to the MRI screening events:
The article has a good discussion on the MRI screening process and recommendations for training/education of MRI personnel, non-MRI personnel, and patients, plus recommendations about the environment and medical equipment.
As noted above, implantable cardiac devices have historically been a major safety concern for patients undergoing MRI, resulting in many patients not getting MRI’s that might have provided important information about their medical problems. A recent study (Bhuva 2019) reported on development of a ‘one-stop’ service for MRI, whereby such devices could be reprogrammed and scans acquired at a single location and visit. They trained a team including administrators, physicians, cardiac physiologists and radiographers and developed a standard protocol. This resulted in increased provision of MRI to such patients and significantly reduced delays in patients getting MRI. Their protocols and checklists are available at mrimypacemaker.com. That article also has an excellent bibliography.
See also our October 2016 What's New in the Patient Safety World column “MRI Safety: There’s an App for That!” that describes an app which attempts to determine whether an MRI can be performed in the presence of certain implants. It considers not only the type of implant but also its location, the type of MRI scan being done, the part of the body being imaged, the strength of the magnet and other issues of configuration of the MRI machine, and other considerations such as the location of the various energy sources relative to the patient’s location in the MRI suite.
The effects of electromagnetic energy may result in thermal injuries from tissue heating, particularly in areas where metallic elements are in contact with skin or organs. ECG leads and electrodes or cables have been implicated most often. But another concern has been transdermal drug patches (see our March 2009 What's New in the Patient Safety World column “Risk of Burns during MRI Scans from Transdermal Drug Patches”). Sometimes those items are ones we would not even thing about. The RF identification tag on certain breast implants can heat up during the MR scan (Wilson 2019).
One concern over the years has been what to do with patients having tattoos. Many color pigments may contain ferrous particles that may interact with the magnetic resonance and many are conductive and could lead to burns. There have been isolated cases of adverse effects of MRI related to tattoos. With the prevalence of tattoos increasing substantially in recent years, many patients with tattoos may have been denied MRI scans. But a recent prospective study (Callaghan 2019) found that, in 330 persons who had one to seven tattoos, only one mild tattoo-related adverse reaction was detected during MRI. That patient had an unpleasant tingling sensation in the tattoo that disappeared within 24 hours. The results suggest a low risk among persons with tattoos when MRI is performed under these specific study conditions. But note that the researchers had strict criteria regarding the size of tattoos: a single tattoo was not allowed to exceed 20 centimeters and tattoos could cover no more than five percent of the body in total.
And, while this is a column on unexpected events during MRI, we’d be remiss if we did not comment on unexpected events after MRI. Of course, we are referring here to detection of incidental findings on the MRI. We always teach our residents to consider before ordering an MRI (or any diagnostic test) what they will do if the result is normal, if it shows what they expected, or if it shows something unexpected. A systematic review and meta-analysis (Gibson 2018) found a pooled prevalence of potentially serious incidental findings was 3.9% on brain and body MRI, 1.4% on brain MRI, 1.3% on thoracic MRI, and 1.9% on abdominal MRI. About half the potentially serious incidental findings were suspected malignancies (brain, 0.6%, thorax, 0.6%, abdomen 1.3%, brain and body 2.3%. Limited data suggested that relatively few potentially serious incidental findings had serious final diagnoses (20.5%). We also refer you to two articles about incidental findings found on MRI scans done for headache evaluations (Evans 2017, Evans 2018). What is not known is what unintended consequences arise from the further testing and interventions that may take place after incidental findings are reported. We must always be ready to deal with the problem of incidental findings any time we order an MRI scan.
Lastly, keep in mind that, as magnets get stronger and stronger, we may see effects not seen with weaker magnets. Last year one study showed that mercury was released from dental amalgams when patients were exposed to 7.0 Tesla MRI magnets (Yilmaz 2018). It’s not known whether any harm comes from such events. But the point is that we must remain vigilant for adverse consequences as imaging becomes more advanced.
Some of our prior columns on patient safety issues related to MRI:
Some of our prior columns on patient safety issues in the radiology suite:
References:
Sadigh G, Applegate KE, Saindane AM. Prevalence of Unanticipated Events Associated With MRI Examinations: A Benchmark for MRI Quality, Safety, and Patient Experience. J Am Coll Rad 2017; 14(6): 765-772 Published online: March 26, 2017
https://www.jacr.org/article/S1546-1440(17)30175-8/fulltext
Forrest W. Pediatric patients use app to prep for MRI scan. AuntMinnie.com 2018; March 2, 2018
https://www.auntminnie.com/index.aspx?sec=rca&sub=ecr_2018&pag=dis&ItemID=120069
Wilson SR, Shinde S, Appleby I, et al. Guidelines for the safe provision of anaesthesia in magnetic resonance units 2019. Guidelines from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society of Great Britain and Ireland. Anesthesia 2019; First published: 03 February 2019
https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14578
Sammet S. Magnetic Resonance Safety. Abdominal Radiology 2016; 41(3): 444–451
March 2016
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848040/
Cross M, Hoff MN, Kanal KM. Avoiding MRI-Related Accidents: A Practical Approach to Implementing MR Safety. J Am Coll Radiol 2018; 15(12): 1738-1744
https://www.jacr.org/article/S1546-1440(18)30762-2/fulltext
Field C. MRI Screening: What’s in Your Pocket? Pa Patient Saf Advis 2018; 15(4). December 19, 2018
http://patientsafety.pa.gov/ADVISORIES/Pages/201812_MRIScreening.aspx
Bhuva AN, Feuchter P, Hawkins A, et al. MRI for patients with cardiac implantable electronic devices: simplifying complexity with a ‘one-stop’ service model. BMJ Qual Saf 2019; Published Online First: 13 February 2019
https://qualitysafety.bmj.com/content/early/2019/02/13/bmjqs-2018-009079
Callaghan MF, Negus C, Leff AP, et al. Safety of Tattoos in Persons Undergoing MRI
N Engl J Med 2019; 380: 495-496 Jan 31, 2019
https://www.nejm.org/doi/full/10.1056/NEJMc1811197?query=featured_home
Gibson LM, Paul L, Chappell FM, et al. Potentially serious incidental findings on brain and body magnetic resonance imaging of apparently asymptomatic adults: systematic review and meta-analysis. BMJ 2018; 363: k4577
https://www.bmj.com/content/363/bmj.k4577
Evans RW. Incidental Findings and Normal Anatomical Variants on MRI of the Brain in Adults for Primary Headaches. Headache 2017; 57(5): 780-791
https://onlinelibrary.wiley.com/doi/abs/10.1111/head.13057
Evans RW. Headache MRI: What to Do With Incidental Findings. Medscape Medical News 2018; August 28, 2018
https://www.medscape.com/viewarticle/901068
Yilmaz S, Adison MZ. Ex Vivo Mercury Release from Dental Amalgam after 7.0-T and 1.5-T MRI. Radiology 2018; Published Online:Jun 26 2018
https://pubs.rsna.org/doi/10.1148/radiol.2018172597
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April 9, 2019
Handoffs for Every Occasion
Handoffs in healthcare (or, for that matter, in any industry) are periods of vulnerability. We’ve done many columns on handoffs but it’s been a while since we last did one and, since then, there have been a number of studies on handoffs in a variety of settings:
The Intraoperative Handoff
One type of handoff we’ve seldom focused on the intraoperative handoff. In our January 6, 2015 Patient Safety Tip of the Week “Yet Another Handoff: The Intraoperative Handoff” we discussed a study by Saager and colleagues (Saager 2014) that showed an 8% increase in the composite of mortality and morbidity for each increase of one handoff. For example, those with 2 transitions had a 17% increase in the composite. Moreover, the increased occurrence of complications with handoffs affected all the individual categories of the composite (cardiac, gastrointestinal, bleeding, infection). Their findings held up after adjustment for multiple potential confounding factors and in sensitivity analyses. The adverse effect of the handoffs was similar for attending anesthesiologists, directed residents, and CRNA’s. While the association does not prove causation, the association is nevertheless striking and implies the intraoperative handoffs were contributory factors to adverse outcomes. The Cleveland Clinic at the time of the study did not have a formal structured handoff process for intraoperative handoffs. The authors suggest adoption of formal protocols, including checklists, as a potential way to reduce the adverse impact of intraoperative handoffs on patient outcomes.
There have been a couple recent studies on the impact of such intraoperative handoffs on patient safety. The first study (Jones 2018) looked at over 300,000 adult patients undergoing major surgeries in Ontario, Canada. The surgeries were anticipated to last at least 2 hours and the patients were anticipated to have at least one night stay in the hospital. They compared outcomes in those cases in which a complete intraoperative handoff of anesthesia care occurred vs. those in which there was no handoff. The primary outcome measure was a composite of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Only 1.9% of cases had a complete anesthesia handoff, though over the 6 year course of the study the percentage steadily increased, reaching 2.9% by the last year of the study. The primary outcome occurred in 44% of the complete handover group compared with 29% of the no handover group. After adjustment, complete handovers were associated with an increased risk of the primary outcome (adjusted risk difference 6.8%), all-cause death (aRD 1.2%), and major complications (aRD, 5.8%), but not with hospital readmission within 30 days of surgery. The authors conclude that the complete handover of intraoperative anesthesia care compared with no handover is associated with a higher risk of adverse postoperative outcomes and suggest limiting complete anesthesia handovers.
Another recent study at a tertiary academic medical center in the US (Rostin 2018) found a considerably higher percentage of handoffs between attending anesthesiologists (9.7%). Their primary outcome measure was a composite of 30-day mortality, readmission and major postoperative complications. Intraoperative handovers were associated with an increased risk of all postoperative adverse events (OR 1.11), 30-day readmission (OR 1.13) and major complications (OR 1.1). They also found that surgery of longer duration (>150 minutes) significantly augmented the effect. But high provider case volume (number of anesthesia cases by provider during the study period over 1106) mitigated the effect. Note that the Rostin study excluded patients if they underwent cardiac surgeries, had operations within 4 weeks prior to the index procedure, or had an ASA score >5.
Like the other studies, these authors conclude that intraoperative transitions of care between attending anesthesiologists are associated with adverse postoperative outcomes, especially when low case volume anesthesia providers are involved and in surgeries of longer duration (>150 minutes).
Point of interest: we require a second formal timeout when an additional surgeon becomes involved in a case (whether for a second procedure or just to participate in the original procedure). But most hospitals do not require a second formal timeout when other members of the OR team change during a procedure!
The OR to ICU Handoff
Researchers prospectively evaluated the effectiveness of standardizing operating room to surgical intensive care unit handoffs in a mixed surgical population (Lane-Fall 2018). The new standardized handoff protocol required bedside clinician communication using an information template. They examined omission of information across 13 topics contained in the handoff template. After standardization, information omissions decreased 21.3% (from 4.7 to 3.7). And, for new ICU patients, information omissions decreased 36.2% (from 4.7 to 3.1). Handoff duration increased after standardization from 4.1 to 8.0 minutes. ICU mortality and length of stay did not change postimplementation.
In our August 22, 2017 Patient Safety Tip of the Week “OR to ICU Handoff Success” we described a structured process for handoffs at the Oregon Health & Science University (OHSU) that resulted in a significant reduction in preventable patient complications (Hall 2017). They provide an example template for the handoff from the anesthesia provider to the critical care team.
The ICU to Ward Handoff
Two recent studies looked at ICU-to-ward transfers. One study (Santhosh 2019), from 3 academic medical centers in the US, compared process maps to identify similarities and differences between ICU–ward transfer processes across the three hospitals and also surveyed residents anonymously about such transfers. 87% of the residents responding to the survey recalled at least one adverse event related to communication failure during ICU–ward transfer. 95% agreed that a well-structured handoff template would improve ICU–ward transfer. Rehabilitation needs, intravenous access/hardware and risk assessments for readmission to the ICU were the most frequently omitted or incorrectly communicated components of handoff notes. Notes often omitted or miscommunicated pending results, active subspecialty consultants, nutrition and intravenous fluids, antibiotics, and healthcare decision-maker information. Though the process vaired across the three sites, all process maps demonstrated flaws and potential for harm in critical steps of the ICU–ward transition.
A Canadian study (de Grood 2018) looked at with transfers from intensive care unit to hospital ward from the perspective of patient, family and provider. The researchers found 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication, and institutional culture. Bed availability could be either a barrier or facilitator for such transfers. They recommend implementing standardized communication tools that streamline provider–provider and provider–patient communication. Communication to facilitate timely, accurate, durable and mutually reinforcing information transfer should be multimodal. Procedures should also provide for managing delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed. They stress the importance of patient- and family-centeredness as a facilitator of high-quality ICU transfers.
One critical factor that should be part of every ICU-to-ward handoff should be verification that medication reconciliation has taken place. A recent study of almost 1000 ICU patients transferred to non-ICU locations (Tully 2019) found that 46% had a medication error occur during transition of care and, among patients with a medication error, an average of 1.88 errors per patient occurred. The most common types of errors were continuation of medication with ICU-only indication (28.4%), untreated condition (19.4%), and pharmacotherapy without indication (11.9%). Factors associated with decreased odds of error included daily patient care rounds in the ICU (odds ratio, 0.15) and orders discontinued and rewritten at the time of transfer from the ICU (odds ratio, 0.36). We have always been sticklers that all orders should be discontinued and then rewritten on such transfers. So, if you are using a structured format and/or a checklist for the ICU-to-ward handoff, make sure one of your items is whether that process has taken place.
Intensivist Handoffs
A study from Brazil (Dutra 2018) found that diagnoses and goals of treatment are either not conveyed or retained 50–60% of the cases immediately after a handover. Daytime clinicians were more sensitive (65% vs 46%) but less specific (82% vs 91%) than nighttime clinicians in anticipating clinical events at night but the positive predictive value of both daytime and nighttime clinicians was low (13% vs 17%). Gaps in diagnosis and anticipation of events were more pronounced in neurologic diagnoses.
The authors conclude that clinicians have limited ability to anticipate events, and the expectation that anticipatory guidance can inform handovers needs to be balanced against information overload. Suggested improvements to benefit communication could include cognitive checklists, prioritizing discussion of neurologic patients, and brief combined clinical examination at handover.
Hospitalist Handoffs
A summary of interviews with several prominent hospitalists (Fink 2019) highlighted some key elements of successful handoffs for hospitalists. One is use of standardized, structured tools like I-PASS (see our several columns on I-PASS listed below). Vineet Arora from the University of Chicago emphasized the importance of succinctness in well-done handoffs.
Arora also suggested "chunking" patients into related groups. For example, one group might include the sickest patients, the ones who are likely to experience a change in condition during the subsequent shift. Another group might be patients who are doing well but require some simple follow-up. Another group could be stable patients with no foreseeable needs.
The importance of carving out a dedicated time and space was emphasized. Harvard’s Stephanie Mueller pointed out that, at Brigham and Women's Hospital, there is a 1-hour overlap between scheduled physician shifts intended to be dedicated to the handoff.
Closing the loop by readback for important information is also a critical element.
Hospitalist schedules that improve continuity are also useful. For example, longer stretches of on-duty days (7 vs 5, for instance) increase the likelihood that the same two physicians (one day, one night) might manage a patient's entire hospitalization.
Structured Handoffs in General Surgery
The European working time directive, implemented in 2004, reduced the number of hours worked by trainees, thus increasing the number and importance of handoffs (or handovers, as they are called across the pond). In response, the Royal College of Surgeons of England produced guidelines on safe handover practice (RCS 2007). These guidelines recommended a minimum dataset for inclusion when handing over patients to incoming surgical teams. A recent study (Jones 2019) looked at the impact of a standardized handover sheet, developed in accordance with these guidelines and designed to encourage use of this minimum dataset. Striking differences were seen in the quality of information handed over after implementation. Significant increases were seen in the documentation of patient location (56% to 87%), documentation of important outstanding clinical tasks (45% to 89%), proportion of patients for whom the occurrence of a senior review was documented (28% to 85%), and documentation of blood results. Though the researchers focused on the impact of the structured handoff sheet, they note that post-intervention more detail was used in verbal handover, and incoming teams often wrote additional information in personal notes during such discussions.
Transfer of Violent Patients from ED to Medical Units
A study (Larson 2019) from the Mayo Clinic used one of our favorite tools, the huddle, to facilitate transfers of violent patients from the emergency departments to medical units and improve staff safety during such transfers. The ED nurse would initiate the huddle process by informing the admitting unit that a patient at risk for violence was being admitted. A huddle form is completed. The admitting care team would then call the ED team so that both teams participated in the handoff call together. They refined the process through iterative Plan–Do–Study–Act (PDSA) cycles. RNs from the ED and the six medical units reported feeling safe during the transfer process 100% of the time after implementation vs. 54.7% at baseline and ED staff satisfaction with the process improved from 53.3% to 75.0%. Given the increasing prevalence of violence to healthcare workers, this process is a welcome improvement.
Resident Handoffs in the ED
Things can slip through the cracks when emergency department physicians change shift. A recent study (Milano 2019) showed that use of a standardized sign-out checklist for emergency medicine residents to complete prior to sign out increased the frequency of discussion of critical tasks remaining for patient care, disposition status, and subjective assessment of quality of sign-out. The checklist included topics of diagnoses, patient care tasks to do, patient disposition, admission team, and patient code status. Compared to the status quo unstructured sign-out, implementation of a standardized checklist improved attendings’ perception of the quality of resident transition of care, discussion of patient care tasks requiring completion, disposition confirmation, necessity for attending clarification, and shorter duration of sign-out process.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The Handback”
December 2014 “I-PASS Passes the Test”
January 6, 2015 “Yet Another Handoff: The Intraoperative Handoff”
March 2017 “Adding Structure to Multidisciplinary Rounds”
August 22, 2017 “OR to ICU Handoff Success”
October 2017 “Joint Commission Sentinel Event Alert on Handoffs”
October 30, 2018 “Interhospital Transfers”
References:
Saager L, Hesler BD, You J, et al. Intraoperative transitions of anesthesia care and postoperative adverse outcomes. Anesthesiology. 2014; 121(4): 695-706.
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1921547&resultClick=3
Jones PM, Cherry RA, Allen BN, et al. Association Between Handover of Anesthesia Care and Adverse Postoperative Outcomes Among Patients Undergoing Major Surgery. JAMA 2018; 319(2): 143-153
https://jamanetwork.com/journals/jama/fullarticle/2668348
Rostin P, Lukannek C, Bose S, et al. Association of Operating Room Handoffs and Patient Centered Outcomes. American Society of Anesthesiologists Anesthesiology Annual Meeting 2018; Abstract A1012; October 13, 2018
Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partially Structured Postoperative Handoff Protocol Improves Communication in 2 Mixed Surgical Intensive Care Units. Findings From the Handoffs and Transitions in Critical Care (HATRICC) Prospective Cohort Study. Annals of Surgery 2018; Publish Ahead of Print November 29, 2018
Hall M, Robertson J, Merkel MM, et al. A Structured Transfer of Care Process Reduces Perioperative Complications in Cardiac Surgery Patients. Anesthesia & Analgesia 2017; 125(2): 477-482
Sample handoff template from the OHSU article.
Santhosh L, Lyons PG, Rojas JC, et al. Characterising ICU–ward handoffs at three academic medical centres: process and perceptions. BMJ Qual Saf 2019; Published Online First: 12 January 2019
https://qualitysafety.bmj.com/content/early/2019/01/12/bmjqs-2018-008328
de Grood C, Leigh JP, Bagshaw SM, et al. Patient, family and provider experiences with transfers from intensive care unit to hospital ward: a multicentre qualitative study. CMAJ 2018; 190 (22) E669-E676
http://www.cmaj.ca/content/190/22/E669
Tully AP, Hammond DA, Li C, Jarrell AS, Kruer RM. Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location.. Crit Care Med 2019; 47(4): 543-549
Dutra M, Monteiro MV, Ribeiro KB, et al. Handovers Among Staff Intensivists. A Study of Information Loss and Clinical Accuracy to Anticipate Events. Crit Care Med 2018; 46(11): 1717-1721
Fink JLW. How Hospitalists Can Improve Shift-to-Shift Patient Handoffs. Medscape Hospital Medicine 2019; January 18, 2019
https://www.medscape.com/viewarticle/907678?src=wnl_edit_tpal&uac=14695HV&impID=1863484&faf=1
RCS (Royal College of Surgeons of England). Safe Handover: Guidance from the working time directive working party. RCS 2007; March 2007
Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. Journal of Patient Safety 2019; 15(1): 7-10
Milano A, Stankewicz H, Stoltzfus J, Salen P. The Impact of a Standardized Checklist on Transition of Care During Emergency Department Resident Physician Change of Shift. Western J Emerg Med. 2019; 20(1): 29-34
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324700/
Larson LA, Finley JL, Gross TL, et al. Using a Potentially Aggressive/Violent Patient Huddle to Improve Health Care Safety. Joint Comm J Qual Pat Saf 2019; 45(2): 74-80
https://www.jointcommissionjournal.com/article/S1553-7250(18)30103-X/fulltext
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April 16, 2019
AACN Practice Alert on Alarm Management
Among our numerous columns on alarm fatigue and alarm management issues, three columns were aimed at helping hospitals meet Joint Commission’s national patient safety goal on alarm safety (see our Patient Safety Tips of the Week July 2, 2013 “Issues in Alarm Management” and August 16, 2016 “How Is Your Alarm Management Initiative Going?” and October 17, 2017 “Progress on Alarm Management”).
The AACN (American Association of Critical-Care Nurses) Practice Alert “Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry” (AACN 2018) is actually a year old now, but a couple recent studies have reinforced one very important point we’d like to emphasize.
Here are the AACN recommendations for bedside caregivers:
Provide proper skin preparation for and placement of ECG electrodes
That includes washing the site with soap and water and wipe the electrode area with a washcloth or gauze to roughen a small area of the skin when appropriate. They stress that alcohol should not be used because it dries out the skin.
Consider daily ECG electrode changes
This is based more on theoretical grounds and case reports and lacks a strong clinical evidence base but it makes good sense.
Use proper oxygen saturation probes and placement
That means placing the probe on a warm extremity and avoiding placement of a fingertip pulse oximetry sensor on the ear.
Check alarm settings at the start of every shift, with any change in patient condition and with any change in caregiver
Again, lesser level of evidence but makes good sense.
Customize alarm parameter settings for individual patients in accordance with unit or hospital policy
Settings should be adjusted according to individual patient’s condition and age to reduce clinically insignificant alarms
AACN recommended strategies for nursing leaders include the following:
Establish an interprofessional team to gather data and address issues related to alarms
See our Patient Safety Tips of the Week July 2, 2013 “Issues in Alarm Management” and August 16, 2016 “How Is Your Alarm Management Initiative Going?” for discussions of who should be on such teams and how you go about collecting data.
Develop unit-specific default parameters and alarm management policies
Collaborate with an interprofessional team, including biomedical engineering, to determine the appropriate default alarm settings for the unit’s patient population.
Provide initial and ongoing education on monitoring systems and alarm management for unit staff
This should be done for new nurses and periodically for all staff. They also note you should budget for appropriate education any time new alarm systems are introduced.
Consider use of an alarm notification system
This would include things like middleware, monitor watchers/technicians, etc. See our October 17, 2017 Patient Safety Tip of the Week “Progress on Alarm Management” for examples of middleware implementations. But also see our February 9, 2016 Patient Safety Tip of the Week “It was just a matter of time…” for what can go wrong with such systems. And a recent AHRQ Web M&M case (Sandau 2019) also illustrates problems that can arise with inadequate communication when telemetry is being monitored remotely.
Develop policies and procedures for monitoring only those patients with clinical indications for monitoring
We consider this one of the most important interventions to reduce unnecessary alarms and reduce alarm fatigue.
This last recommendation is the one we want to stress. In multiple columns we have emphasized that the biggest “bang for the buck” usually comes from eliminating unnecessary telemetry (see, for example, our October 2014 What's New in the Patient Safety World column “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”). We’ve stressed that such policies should include not only criteria for initiation of telemetry but should also include criteria for cessation of telemetry.
Clinicians and researchers conducted a study at UCSF where they randomized an EHR alert randomized to half of the teams on the general medicine service (Najafi 2018). The alert displayed during daytime hours when physicians attempted to place an order for patients not in the intensive care unit whose telemetry order duration exceeded the recommended duration for a given ind1ication. The alert prompted a significant reduction in telemetry monitoring duration (8.7 fewer hours per hospitalization) with no significant change in rapid-response calls or medical emergency events. The most common physician response to an alert was to discontinue telemetry monitoring (62%). They authors conclude that a targeted EHR alert can safely and successfully reduce cardiac monitoring by prompting discontinuation when appropriate. They also note that this single-component electronic intervention is less resource intensive than typical multicomponent interventions that include human resources.
Another study (Sendelbach 2019) evaluated the impact of implementation of an electronic order set based on the American Heart Association practice standards for electrocardiographic monitoring on the occurrence of appropriate monitoring. Implementation of the order set was associated with an increase in appropriate monitoring (from 48.0% pre-intervention to 61.2% post-intervention). The largest increase was in ordering by medical residents, with appropriate monitoring increasing from 30.8% to 76.5% (note that medical residents had mandatory education on the order set, whereas hospitalists on received a one-slide overview on the order set). There was no significant increase in adverse patient outcomes. Also, more patients had fewer days of monitoring without an indication for monitoring after implementation but the difference was significant for the subgroup of medical residents.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
AACN (American Association of Critical-Care Nurses). Practice Alert. Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry. AACN April 3, 2018
Sandau KE, Funk M. What Happened on Telemetry? AHRQ PSNet Web M&M 2019; March 2019
https://psnet.ahrq.gov/webmm/case/473
Najafi N, Cucina R, Pierre B, et al. Assessment of a Targeted Electronic Health Record Intervention to Reduce Telemetry Duration. A Cluster-Randomized Clinical Trial. JAMA Intern Med 2018; Published online December 10, 2018
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2717954
Sendelbach S, Sandau KE, Smith L, et al. Implementing Practice Standards for Inpatient Electrocardiographic Monitoring. Am J Crit Care 2019; 28(2): 109-116
http://ajcc.aacnjournals.org/content/28/2/109.full
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April 23, 2019
In and Out the Door and Other OR Flow Disruptions
We’ve often discussed the role of unnecessary foot traffic in the OR and opening of OR doors and the potential to increase the risk for surgical site infections. Such traffic likely also has the effect of increasing distractions and interruptions in the OR, which are factors contributing to many adverse events.
In our March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” we noted a study (Lynch 2009) that suggested increased foot traffic may be factor related to prolonged procedures that increases the likelihood of surgical site infections.
In our November 24, 2015 Patient Safety Tip of the Week “Door Opening and Foot Traffic in the OR” we discussed a study from Johns Hopkins that formally studied how often OR doors are opened during joint arthroplasty surgeries and the impact on OR air flow (Mears 2015). The researchers measured how often and for how long OR doors were opened during 191 hip and knee arthroplasty procedures. They also measured air pressures in the OR and adjacent corridors. They found that, on average, OR doors were open 9.5 minutes per case and the average time between door openings was 2.5 minutes. As you’d expect the number and duration of door openings correlated with the length of surgery. In 77 of the 191 cases positive pressure within the OR was defeated. The implications are obvious. While they found only one surgical infection in the 191 cases, the effects of the door opening on OR pressure and air flow theoretically would predispose to surgical infections. OR’s have positive pressure to avoid flow of air and airborne pathogens from nonsterile adjacent areas.
Andersson and colleagues (Andersson 2012) investigated air quality, expressed as colony-forming units (CFU)/m3, in OR’s during orthopedic trauma surgery. They found a strongly positive correlation between the total CFU/m3 per operation and total traffic flow per operation, after controlling for duration of surgery. There was also a correlation with the number of persons present in the OR and surgery case duration. The authors concluded results of this study support interventions aimed at preventing surgical site infections by reducing traffic flow in the OR.
Discussion with Dr. Andersson, the lead author of that study, revealed that door openings related to social visits and for no detectable reasons together accounted for 27% of the traffic flow (Rosenthal 2019). The leading reasons doors were opened were for supplies (26%) and for staff breaks (20%). Only 7% of door openings during surgery were for expert consultation. 14% of the door openings occurred while the wound was open.
Weiser et al. (Weiser 2018), measuring pressure and air flow, found that opening single doors did not allow contaminated air into the OR but simultaneous opening of two doors does allow contaminated air to flow into the OR. In a commentary on the Weiser study (Hofheinz 2018) it was noted that over half of door opening events take place during room and sterile tray set up and it is possible that there are simultaneous double door opening events during this time, allowing contaminated air into the operating room with possible contamination of the trays. Many interventions have focused on restricted door opening only once the initial incision is made but this study suggests the OR should be restricted to a single door during both room set up and the actual surgical procedure. It also suggests that sterile instrument trays should be covered with sterile towels after opening until they are ready for use.
But there is even another scenario that would not require both doors to open. As reported by Rosenthal (Rosenthal 2019) in an interview with lead author Edmiston (Edmiston 2005) they identified a sink in an anteroom adjacent to an OR as the source of potential contamination. They discovered that whenever the faucet was turned on and water hit the sink, it created an aerosol. Anyone walking through the anteroom when the aerosol was present could carry the bacteria into the OR, which could then contaminate a surgical wound.
Okay, so door openings and closings in the OR may be bad. What do we do about it? First, we need to understand the reasons for OR door opening/closing. Rovaldi and King (Rovaldi 2015) found the top five reasons for unnecessary traffic in an OR were
But they found different reasons for door openings during the pre-incision and post-incision time frames. During the pre-incision period, causes of door openings included supply procurement, sterility of trays, equipment requirements, and patient comfort items. Although many of the reasons overlap both periods, the main causes of door openings during the post-incision period were communication, vendor foot traffic, and personnel reliefs.
Loisona et al. (Loisona 2017) found the following reasons for entries to/exits from the OR:
You should begin your quality improvement program for limiting unnecessary OR door opening by measuring the frequency of such opening and determining the reasons for such openings. There are inexpensive magnetic or infrared devices you can install to count the number of times the doors are opened and closed. There are several ways to identify the reasons. One would be to have a student or someone simply observe and ask the reason every time someone enters or leaves the OR or opens/closes the doors. In our December 2017 What's New in the Patient Safety World column “A Fix for OR Foot Traffic?” we suggested is keeping a log where staff are required to log in every time they leave and enter the OR for each case, similar to what was done in the Canadian study (Camus 2016). Of course, there will be blowback from many of your staff that this might be time consuming. It need not be. How many of you have an electronic device like an Amazon Echo or a Google Home Assistant and say something like “Alexa, add paper towels to my grocery list.”? Alexa creates a grocery list and adds paper towels to it. You could do the same with such a device in your substerile OR area and, when the OR door alarm sounds, require the person entering the OR to say something like “Alexa, this is surgical tech Yvonne Jones entering the OR with new equipment” and Alexa could add the name of the staff member and the reason to the log created when the case began. Voila! It took years before we learned about barcoding from our supermarkets and applied it to healthcare. It’s time we take a lesson from our hi-tech kitchens! We’ll bet that simply requiring such a log will probably result in some reduction in unnecessary door openings.
Understanding those reasons logically leads to interventions that might be expected to reduce unnecessary foot traffic and door opening/closing.
Hamilton and colleagues (Hamilton 2018) found that simply monitoring door opeinings during joint arthroplasty was not effective in reducing the occurrences. However, after a novel educational seminar given to all personnel, there was a significant reduction in the incidence of operating room door openings, reducing a potential risk factor for surgical site infections.
A few studies that relied primarily on educational and behavioral interventions have had moderate success in reducing OR traffic. Pulido et al. (Pulido 2017) compared traffic rates in hip and knee arthroplasty cases against traffic rates during non-arthroplasty cases to examine the effects of verbal interventions implemented by the surgeon to reduce intraoperative traffic. The surgeon in the interventional group implemented verbal protocols to OR staff to limit excessive intraoperative traffic. Comparing the 2 groups, the interventional group averaged 33 movements per hour while the noninterventional group averaged 46 movements per hour. The authors conclude that their results suggest that operative room traffic can be reduced through simple verbal protocols established by the surgical team. DiBartola et al. (DiBartola 2019) implemented a multidisciplinary intervention that included education, OR signage, and team-based accountability and behavioral interventions. Average door openings per minute decreased by 22% after intervention. They concluded that behavioral interventions that focus on education, awareness, and efficiency strategies can decrease overall OR traffic for orthopedic cases.
Others have not noted significant improvements with educational programs alone. We all know that education and training are necessary for most quality and patient safety interventions, but we also know that they are not particularly effective in producing desired results, particularly on a sustained level. “Nudges” are a bit more useful. But the best interventions are constraints and forcing functions. Another key to successful interventions is providing alternative actions when we use any sort of alert or warning, something we’ve clearly learned in CPOE implementations. One example of the latter is providing a means of communication between those outside the OR and those inside the OR. That could be an intercom, though some have used phone systems. These allow questions to be asked and answered without opening the OR doors.
In our December 2017 What's New in the Patient Safety World column “A Fix for OR Foot Traffic?” we noted a study which looked at the impact of an audible alarm on reducing OR foot traffic during total joint arthroplasties (Eskildsen 2017). Researchers placed an audible alarm on the substerile operating room door that sounded continuously when the door was ajar. This resulted in a significant difference in the overall mean door openings per minute between the period with no alarm and with an alarm. Prior to the door alarm, the substerile door was opened a mean of 88.12 times per case, or 0.53 times per minute. After the door alarm was installed, door openings decreased to a mean of 69.46 times per surgery, or 0.42 times per minute. However, this effect slowly decreased over the time of the intervention.
The percentage of time the door was left ajar per case also decreased significantly with the alarm. Prior to the intervention the door remained open for a mean of 14.45 minutes per case, or 8.65% of overall surgical time. After the door alarm was installed the mean duration of time that the door remained open decreased to 10.81 minutes per surgery, or 6.63% of the overall surgical time.
Unfortunately, the study was not large enough to determine whether the reduced door opening had an impact on surgical infection rates. But the findings certainly suggest that this may be one way to reduce such infections. However, we have 2 cautions about such an alarm. First, you need to be extremely careful that the alarm does not produce distractions or interruptions that might lead to other errors in the OR. Second, as with any alarm system, alarm fatigue is likely to occur.
Rovaldi and King (Rovaldi 2015) implemented a 3-phase multidisciplinary educational and operational quality improvement initiative to assess the effect of process interventions on reducing OR door openings. They analyzed the effectiveness of door opening deterrents (eg, a pull shade, magnetic yellow caution tape across the door frame) and changes in traffic processes (eg, clear‐covered implant carts). The interventions and process changes showed a 50% reduction in door openings compared to the baseline. See our comments below on this study.
In our July 26, 2016 Patient Safety Tip of the Week “Confirmed: Keep Your OR Doors Closed” we highlighted a study that demonstrated a program to reduce unnecessary door openings may reduce surgery-related infections (Camus 2016). A Canadian hospital did a manual count of door openings during total joint replacement operations and revision procedures. They counted between 42 and 70 door openings per operation from incision time to joint capsule closure time. Operations averaged 75 minutes. Reasons for entering and exiting the OR during operations included retrieving charts, instruments, or equipment, and taking a break. Next their CUSP (Comprehensive Unit-Based Program) team brainstormed and came up with key changes, including stopping all traffic in and out of the OR between total joint capsule opening and closure, communicating by phone, and increasing the use of templates to identify implant size prior to each operation. They also put a sign on the OR door reminding staff to minimize traffic and asking them to record why they are entering the OR during an operation. Subsequent traffic audits taken every six months indicated an amazing reduction in OR traffic from between 42 and 70 door openings to 3.2 door openings per case. They felt this intervention may have contributed to a decrease in orthopedic SSIs from 2.8 percent to 2.1 percent. The Canadian team is expanding its program to multiple other services and other hospitals in their multi-hospital system.
Saver (Saver 2014) recommended the following strategies:
Thomas (Thomas 2018) has the following suggestions:
AORN’s 2019 Guidelines will also include a list of 14 interventions for reducing door opening (AORN 2019).
The nature and timing of any signage is important. Rovaldi et al. (Rovaldi 2015) had an interesting observation. At one point prior to their quality improvement project, magnetic signs stating “Do Not Enter” or “Implants in Use. Do Not Enter” had been placed on the OR doors. But these were never removed from the doors. Hence, they had minimal impact. The most important signage they used was on a pull-down shade that was pulled down at the time of incision to warn outsiders not to enter the OR. This was a shade that, when pulled down, covered half the window on the door and stated “Incision” and would be seen from the sterile inner core area. Worried you might forget to pull down the shade? Add this to your timeout/safe surgery checklist! That sign is basically a version of one of the interventions we’ve recommended in several of our columns – a sign akin to the “On the Air” sign in TV, radio, or recording studios that lights up when the case is in progress.
The Rovaldi study (Rovaldi 2015) is worth your reading because it has a good discussion of problems encountered in any change endeavor. They found that a substantial reduction in door opening following their phase 1 was not sustained. So, the QI team went back to various stakeholder meetings, identified champions, and offered rewards for useful suggestions. That led to one key suggestion about the signage: the pull-down shade. This was a shade that, when pulled down, covered half the window on the door and stated “Incision” and would be seen from the sterile inner core area. The other key suggestions that came out of those meetings were: use of magnetic yellow caution tape across the door frame, and clear-covered implant carts. And providing feedback to all about both the frequency of door opening and SSI rates was another important step in sustaining the improvement.
They also noted a vendor issue (Please don’t get us started on the issue of vendors in the OR!) where vendors needed additional implant sizes or having to go into or out of the room for communication reason. That led to the suggestion of the clear-covered implant carts. Note that the Camus study noted above (Camus 2016) promoted use of templates to identify implant size prior to each operation to minimize the need for going in and out of the OR for implants.
Though the Rovaldi team liked the idea of the yellow magnetic tape across the OR door, it had limited usefulness in practice because draping the tape was often forgotten.
We mentioned earlier that unnecessary OR traffic likely also has the effect of increasing distractions and interruptions in the OR, which are factors contributing to many adverse events. A recent study (Joseph 2018) went beyond unnecessary foot traffic and looked also at other “minor” flow disruptions in the OR that may increase the risk for patient safety issues. The researchers looked at equipment malfunction, door openings, case irrelevant conversations, loud noises and alarms, communication breakdowns, environmental clutter and constrained spaces. They also took into account that the physical layout of the OR and the OR environment have important roles in promoting or preventing such flow disruptions. It is an excellent review of activities that occur in various “zones” of the OR that lead to minor or major flow disruptions.
Also we’ve discussed in numerous columns how use of presurgical “huddles” or briefings and postsurgical debriefings may help identify issues that can lead to reduction in surgical duration and unnecessary OR traffic (see our December 30, 2014 Patient Safety Tip of the Week “Data Accumulates on Impact of Long Surgical Duration”). The pre-op huddle can help ensure you have all necessary equipment and supplies so you don’t have to open and close doors to find them after a case has begun. And the post-op debriefing can identify things that should have been in the OR so that your next cases don’t have the same problems. If you use the type of log we described earlier, we’d suggest you make review of the log part of your post-op debriefing. You are doing debriefings after every case, aren’t you?
Our prior columns focusing on surgical OR foot traffic and door opening:
References:
Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52
http://ajm.sagepub.com/content/24/1/45.abstract
Mears SC, Blanding R, Belkoff SM. Door Opening Affects Operating Room Pressure During Joint Arthroplasty. Orthopedics 2015; 38(11): e991-e994
Andersson AE, Bergh I, Karlsson J, et al. Traffic flow in the operating room: An explorative and descriptive study on air quality during orthopedic trauma implant surgery. American Journal of Infection Control 2012; 40(8): 750-755
https://www.ajicjournal.org/article/S0196-6553(11)01248-X/fulltext
Rosenthal T. OR Air Contamination Standards Needed to Control SSI Risk. Anesthesiology News 2019; April 5, 2019
Weiser MC, Shemesh S, Chen DD, et al. The Effect of Door Opening on Positive Pressure and Airflow in Operating Rooms. Journal of the American Academy of Orthopaedic Surgeons 2018; 26(5): e105–e113
Hofheinz E. Double OR Doors = Infection Risk! Orthopedics This Week 2018; March 6, 2018
https://ryortho.com/breaking/double-or-doors-infection-risk/
Edmiston CE, Seabrook GR, Cambria RA, et al. Molecular epidemiology of microbial contamination in the operating room environment: Is there a risk for infection? Surgery 2005; 138(4): 573-579; discussion 579-582
https://www.surgjournal.com/article/S0039-6060(05)00421-6/abstract
Rovaldi CJ, King PJ. The Effect of an Interdisciplinary QI Project to Reduce OR Foot Traffic. AORN Journal 2015; 101(6): 666-681
https://aornjournal.onlinelibrary.wiley.com/doi/pdf/10.1016/j.aorn.2015.03.011
Loisona G, Troughtonb R, Raymond F, et al. Compliance with clothing regulations and traffic flow in the operating room: a multi-centre study of staff discipline during surgical procedures. Journal of Hospital Infection 2017; 96(3): 281-285
https://www.sciencedirect.com/science/article/pii/S0195670117301792
Camus S. Operating Room Traffic Monitoring Improves Patient Safety. Abstract session presentation at the 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Conference. July 18, 2016 as reported in ACS (American College of Surgeons). Minimizing Operating Room Traffic May Improve Patient Safety by Lowering Rates of Surgical Site Infections. ACS Press Release July 18, 2016
https://www.facs.org/media/press-releases/2016/nsqip-ssi-071816
Hamilton WG, Balkam CB, Purcell RL, et al. Operating room traffic in total joint arthroplasty: Identifying patterns and training the team to keep the door shut. Am J Infect Control 2018; 46(6): 633-636
https://www.ajicjournal.org/article/S0196-6553(18)30007-5/fulltext
Pulido RW, Kester B, Schwarzkopf R. Effects of Intervention and Team Culture on Operating Room Traffic. Quality Management in Health Care 2017; 26(2): 103-107
https://www.ingentaconnect.com/content/wk/qmh/2017/00000026/00000002/art00007
DiBartola AC, Barron C, Smith S, et al. Decreasing Room Traffic in Orthopedic Surgery: A Quality Improvement Initiative. American Journal of Medical Quality 2019; First Published January 17, 2019
https://journals.sagepub.com/doi/abs/10.1177/1062860618821180
Eskildsen SM, Moskal PT, Laux J, Del Gaizo DJ. The Effect of a Door Alarm on Operating Room Traffic During Total Joint Arthroplasty. Helio Orthopedics 2017; 40(6): e1081-e1085
Saver C. OR traffic data demonstrate need to reduce door openings. OR Manager 2014; 30(7) 1-3
https://www.ormanager.com/wp-content/uploads/2014/07/0714_ORM_10_OR_traffic.pdf
Thomas M. Infection Prevention: Are You Opening the Door to SSIs? Simple steps to reduce OR foot traffic - a preventable infection risk. Outpatient Surgery Magazine 2018; 19(8): 26-29 August 2018
http://www.outpatientsurgery.net/_media/pop/print-article?id=15517
AORN (Association of periOperative Registered Nurses). 2019 Guidelines: Be Ready For 3 Big Changes. AORN Blog 2019; January 6, 2019
https://www.aorn.org/blog/2019-guidelines
Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. BMJ Qual Saf 2018; Published Online First: 29 August 2018
https://qualitysafety.bmj.com/content/early/2018/08/29/bmjqs-2018-007957
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April 30, 2019
Reducing Unnecessary Urine Cultures
In this day and age of the emergence of multi-drug-resistant organisms, antibiotic stewardship is an extremely important concept. Treatment of asymptomatic bacteriuria is an example of inappropriate use of antibiotics that should be avoided in most cases. In our December 18, 2012 Patient Safety Tip of the Week “Unintended Consequences of the CAUTI Measure?” we noted that, because of CAUTI pay-for-performance (P4P) measures, many hospitals were screening for UTI’s on admission so they could use the “present on admission” provision to avoid financial penalties. That probably resulted in many patients receiving unnecessary treatment for UTI’s. In addition, at many hospitals, physicians routinely order urinalyses and urine cultures on admission.
Most guidelines do not recommend screening for UTI’s in asymptomatic patients, with certain exceptions such as pregnant women. Unnecessary screening results in increased costs due to lab costs, antibiotic costs, and possibly extension of length of stay. But it also potentially leads to development of resistant bacterial strains from overuse of antibiotics. Therefore, good antibiotic stewardship should include implementation of programs to reduce or avoid unnecessary screening for urinary tract infections.
Clinicians and researchers at Barnes-Jewish Hospital implemented a program to reduce such unnecessary screening (Munigala 2019). Their intervention consisted of notifications to providers, changes to order sets, and inclusion of urine culture reflex tests in commonly used order sets. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention), a 45% reduction in the urine cultures ordered. The intervention saved approximately $104,000 in laboratory costs alone over the 15-month period. They did not have available antibiotic costs to assess likely additional savings from reduced antibiotic use.
The CPOE intervention they implemented was setting the default option to urine dipstick testing followed by a bacterial culture if positive (i.e. reflex testing), rather than a culture alone, In our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts” we noted the importance of considering appropriate default options when designing order sets. One of the cognitive biases we see is the “default bias”, in which it is a natural tendency to select default options when several options are possible.
The authors conclude that CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.
A recent survey (Sullivan 2019) investigated interventions used by acute-care hospitals to reduce the detection of asymptomatic bacteriuria. Half of the respondents reported using reflex urine cultures but with varied urinalysis criteria and perceived outcomes. Other diagnostic stewardship interventions for urine culture ordering and specimen quality were less common.
Timely is the 2019 Update by the Infectious Diseases Society of America (IDSA) of its Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria (Nicolle 2019). It reiterates many of the recommendations from its 2005 guideline, but also addresses the issue of screening in some special populations.
The guideline still recommends screening for and then treating asymptomatic bacteriuria in pregnant women (4-7 days of antibiotics is recommended for pregnant women with asymptomatic bacteriuria). Screening and treatment is also recommended for patients undergoing endoscopic urologic procedures associated with mucosal trauma.
The guideline recommends against screening for asymptomatic bacteriuria in infants and children, healthy premenopausal, nonpregnant women or healthy postmenopausal women, diabetic patients, patients undergoing elective nonurologic surgery, those planning to undergo surgery for artificial urine sphincter or penile prothesis implantation, or implanted urological devices.
One special population is older patients with cognitive impairment. In those with bacteriuria and delirium or a fall and without local genitourinary symptoms or other systemic signs of infection (eg, fever or hemodynamic instability), the guideline recommends assessment for other causes and careful observation rather than antimicrobial treatment.
Another special population is the older functionally impaired adult. The guideline recommends against screening for or treating asymptomatic bacteriuria in both community-dwelling persons and those in long-term care facilities.
For those with solid organ transplants other than renal transplants, the guideline recommends against screening for or treating asymptomatic bacteriuria. For renal transplant patients >1 month post-transplant, the guideline recommends against screening for or treating asymptomatic bacteriuria. For those in the first month following transplant, the guideline notes insufficient evidence to make any recommendation.
For high-risk neutropenia (absolute neutrophil count [ANC] <100 cells/mm3, ≥7 days’ duration, following cytotoxic chemotherapy) the guideline makes no recommendation
for or against screening for treatment of asymptomatic bacteriuria. For those with low-risk neutropenia, they note that there is no evidence to suggest that asymptomatic bacteriuria has greater risk than for the nonneutropenic population.
What about those patients with indwelling urethral catheters? For those with a short-term indwelling urethral catheter (<30 days) or those with long-term indwelling catheters, the guideline recommends against screening for or treating, though it makes no recommendation for or against screening or treating at the time of catheter removal.
For patients with spinal cord injuries (SCI), the guideline recommends against screening for or treating but acknowledges that clinical signs and symptoms of UTI experienced by patients with SCI may differ from the classic genitourinary symptoms experienced by patients with normal sensation. It notes the atypical presentation of UTI in these patients should be considered in making decisions with respect to treatment or nontreatment of bacteriuria. Note that our own practice is that, when signs and symptoms of autonomic dysreflexia increase in spinal cord-injured patients, we always look for evidence of a UTI.
The U.S. Preventive Services Task Force also has just put out a Draft Recommendation Statement on Asymptomatic Bacteriuria in Adults: Screening (USPSTF 2019). Opportunity for public comment expires on May 20, 2019 so this is not yet an official recommendation. However, you may wish to see the associated evidence review (Henderson 2019).
The IDSA guideline happens to come at the same time a study was published showing that, in elderly patients with proven or suspected UTI in the primary care setting, no antibiotics or delayed antibiotics were associated with a significant increase in bloodstream infection and all-cause mortality compared with immediate antibiotics (Gharbi 2019). That study, however, excluded patients with asymptomatic bacteriuria and those results should not dissuade us from following the ISDA guideline.
Our other columns on urinary catheter-associated UTI’s:
References:
Munigala S, Rojek R, Wood H, et al. Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infection Control and Hospital Epidemiology 2019; Published online: 21 February 2019: 1-6
Sullivan KV, Morgan DJ, Leekha S. Use of diagnostic stewardship practices to improve urine culturing among SHEA Research Network hospitals. Infection Control and Hospital Epidemiology 2019; 40(2): 228-231 Published online: 07 December 2018
Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2019; Published: 21 March 2019
https://www.idsociety.org/practice-guideline/asymptomatic-bacteriuria/
USPSTF (US Preventive Services Task Force). Draft Recommendation Statement. Asymptomatic Bacteriuria in Adults: Screening. USPSTF 2019
Henderson JT, Webber EM, Bean SI. Screening for Asymptomatic Bacteriuria in Adults: An Updated Systematic Review for the U.S. Preventive Services Task Force. AHRQ 2019; April 2019
Gharbi M, Drysdale JH, Lishman H, et al. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study. BMJ 2019; 364: l525 (Published 27 February 2019)
https://www.bmj.com/content/364/bmj.l525
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May 7, 2019
Simulation Training for OR Fires
Some serious events are sufficiently rare that healthcare professionals may not be prepared to properly deal with them. Hence, hospitals and health systems need to include preparation for dealing with such occurrences. Surgical fires are one such example. In our many prior columns on surgical fires, we’ve stressed the importance of drills to prepare staff for the occurrence of a surgical fire. Simulation exercises are a good way to help staff prepare for emergencies.
Two excellent recent papers have focused on simulation exercises to prepare for surgical fires. Keane and Pawlowski (Keane 2019) describe the process at Boston’s Beth Israel Deaconess Hospital. They simulate a laparoscopic cholecystectomy and use a mannequin in their very realistic OR simulation center. They go through the usual prepping and draping and do a surgical timeout. A surgical fellow then prepares the laparoscope and sets it at his/her side while he/she and the surgeon begin to make incisions for port placement. A plume of smoke arises where the laparoscope has contacted drapes (see the full article for their unique mechanism for generating smoke and even projecting images of flames!). The participants respond by removing the drapes and any smoldering material that may harm the patient. The anesthesiologist assesses the patient’s airway and turns off all gases. The RN circulator provides normal saline to douse any flames or smoldering tissue on the patient. The RN circulator also activates a “code red” in the OR and brings the fire extinguisher into the room.
The team then debriefs and analyzes the various roles and responses that occurred during the simulation exercise. They also discuss things like availability of equipment and supplies. One person serves as the event manager. That person does not perform any specific task, but, rather, provides a global assessment and can assign new tasks as needed throughout the event.
It’s difficult to assess the impact of simulation when the real events are rare. The second paper, however, assessed both competency and confidence in handling fire-related safety after simulation. Kishiki and colleagues (Kishiki 2019) examined the effectiveness of OR fire simulation scenarios as a supplement to classroom-based training for managing OR fires. Groups were randomized. One group participated in one simulation after a classroom didactic session. The other group received two simulations, one before and one after the classroom didactic session. Competency scores were assessed for both groups. Those scores were higher for the group receiving 2 simulations and also improved after the second simulation. In addition, confidence scores were higher regarding fire safety-related tasks in the group undergoing 2 simulations.
Some of the elements you would assess during OR fire simulations are:
But keep in mind that these simulations only prepare staff to mitigate harm when a surgical fire occurs. In all likelihood, the patient will have already suffered some harm. The responses are primarily to limit the harm and begin to address harm that has already occurred to the patient.
These simulations should not distract from the primary goal: preventing surgical fires. Our previous columns have discussed in detail each of the elements of the “fire triad” (fuel, oxidizer, and heat source) and focused on key elements in prevention of surgical fires. These include assessing the risk of surgical fire, using tools such as the SF VAMC Surgical Fire Risk Assessment Protocol, developed at the San Francisco VA as part of an effort to promote fire safety in the OR (Murphy 2010), the Christiana Fire Risk Assessment Score or the AORN Fire Risk Assessment Tool.
Then, it is important to ensure that any alcohol-based skin preps have had adequate time to dry and have not pooled under drapes. And, probably most importantly, care needs to be taken to avoid free flow of supplemental oxygen. If oxygen is being used, there needs to be clear coordination between the surgeon and anesthesiologist to avoid the flow of oxygen while an electrocautery device, or other potential heat source, is being used.
We think you will find the AORN Fire Risk Assessment Tool Instructions to be an important resource since it spells out in detail all the steps that need to be taken when you have determined there is substantial risk for a surgical fire.
Another point we’d like to reiterate is that surgical fires are now most often occurring during what would be considered relatively “minor” procedures (eg. temporal artery biopsies, plastic procedures, or removal of skin lesions on the head/neck). We speculate there may be a couple reasons for that. One is that we probably “let our guard down” in dealing with such procedures, thinking they are simple procedures where little can go wrong. The other is that in such cases there may be no need for supplemental oxygen, yet supplemental oxygen is sometimes routinely provided. In others, use of supplemental oxygen is not anticipated but something occurs during the procedure that leads to its use.
We hope you’ll look at the many useful recommendations in our previous columns (listed below). And, of course, we again refer you to the valuable resources on surgical fires provided by ECRI Institute, AORN, the FDA, Christiana Care Health System and the APSF.
Our prior columns on surgical fires:
References:
Keane J, Pawlowski J. Using Simulation for OR Team Training on Fire Safety. AORN Journal 2019; 109(3): 374-378 First Published:27 February 2019
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12630
Kishiki T, Su B, Johnson B, et al. Simulation training results in improvement of the management of operating room fires—A single-blinded randomized controlled trial. Am J Surg 2019; Published online: March 4, 2019
https://www.americanjournalofsurgery.com/article/S0002-9610(19)30011-X/fulltext
SF VAMC Surgical Fire Risk Assessment Protocol
https://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
Murphy J. A New Effort to Promote Fire Safety in the OR. Topics In Patient Safety (TIPS) 2010; 10(6): 3
http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
Christiana Fire Risk Assessment Score
AORN Fire Prevention Assessment Tool
AORN Fire Prevention Assessment Protocol
AORN (Association of periOperative Registered Nurses). AORN Fire Safety Tool Kit.
Accessed September 3, 2018
ECRI Institute. Surgical Fire Prevention.
https://www.ecri.org/surgical_fires
Christiana Fire Risk Assessment
https://christianacare.org/forhealthprofessionals/education/fireriskassessment/
FDA (US Food & Drug Administration). Recommendations to Reduce Surgical Fires and Related Patient Injury: FDA Safety Communication. FDA Safety Communication 2018; May 29, 2018
APSF (Anesthesia Patient Safety Foundation). Resources. Fire Safety Video. Prevention And Management Of Operating Room Fires.
http://www.apsf.org/resources/fire-safety/
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May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
Wrong-site surgeries have not gone away. The Joint Commission sentinel event statistics for 2018 (TJC 2019) show that wrong-site surgery was the third most frequently reported sentinel event (94 cases). Site marking has been one of the most important interventions to prevent cases of wrong-site surgery or other wrong-site procedures. But, one area of concern is the situation in which laterality is not involved or other “difficult-to-mark” sites are involved.
The Joint Commission’s Universal Protocol requires, at a minimum, the site be marked when there is more than one possible location for the procedure and when performing the procedure in a different location could harm the patient. It recommends:
The Joint Commission’s National Patient Safety Goals Effective January 2019 (TJC 2018) require that: “A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum). Note: Examples of other situations that involve alternative processes include: minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice, teeth, premature infants, for whom the mark may cause a permanent tattoo.”
Examples of sites that are difficult, or impossible, to mark include structures like perineum, mucosal surfaces such as with frenectomy procedures, internal organs, casted limbs, lateralized organs. Others include procedures performed on midline organs/structures such as the umbilical, perineal, anal or penile areas, endoscopic or other procedures performed through the mouth, anus or urethral meatus, and single organ cases such as caesarean section, midline sternotomy, laparoscopy, cholecystectomy, splenectomy, laparotomy or urethrotomy. There are also occasional instances where patients refuse site markings.
The Child Health PSO (Patient Safety Organization) recently analyzed wrong-site surgeries and found that alternative site marking policies often were not followed or were lacking in some respects (CHA 2019). They noted the policies should:
They recommend use of visual marking methods accessible to the entire procedural team and have some specific recommendations for certain surgery types:
The recommendations go on to discuss identifying which procedures should be subject to an alternative marking protocol, the role of timeouts, how to do simulations and use real-time reminders to help ensure compliance with the policies, auditing, and what to do in cases where patients or families refuse site marking.
One of the resources they relied upon was from Boston Children’s Hospital (Norton 2011). They had developed an Alternative Site Marking Form. It was a paper form that includes a body diagram for situations when normal site marking would not be acceptable or practical. Clinicians identify the location of the surgical site by initialing the site on the form. Before surgery, the physician marks the diagram with his or her initials by following the same guidelines established for routine site marking. Several years earlier their dental service had begun using a dental diagram or dental radiograph to indicate which operative tooth name(s) and number(s) are indicated for the procedure. The new form they developed included on the back side a close-up of a face, a diagram of an open mouth, and diagrams of male and female genitalia. The open mouth diagram is intended for oral mucosa surgery sites as opposed to teeth (the dentists still use a more specific dental diagram or radiographs). See the Norton paper (Norton 2011). for a copy of the diagram.
The Minnesota Hospital Association has a Safe Site Toolkit that includes good site marking recommendations and guidance and includes a dental chart.
Laparoscopic procedures are also problematic since the incision is typically made in the midline but the target of the procedure may be on one side. A recent report of a hemicolectomy done on the wrong side (CDPH 2018) did not discuss the role of site marking. Laparoscopic oophorectomy is probably more common and might involve just one ovary so there needs to be a way to clearly delineate laterality so that all the OR staff understand which side will be removed. We’d anticipate that use of a form with a diagram, like that in the Norton paper (Norton 2011), would be useful in such cases.
The Minnesota Hospital Association recommendations noted above do comment on procedures with midline incisions but internal laterality. They suggest the incision site be marked with the surgeon’s initials and an arrow to indicate the internal side. Alternatively, they suggest marking on a diagram or use of an armband on the correct side.
Spine surgery classically presents a specific problem. Since the spine is a midline structure, laterality is usually not a prime consideration. However, getting the correct spinal level is a prime consideration. Surgeons typically use radiopaque markers and intraoperative X-rays to mark the correct spinal level. But sometimes the images are poor due to patient or technical issues and other times there may be anomalous anatomy that leads to incorrect level marking. Researchers at Johns Hopkins developed an algorithm, called LevelCheck, to assist in identifying and marking the correct spinal level. “The LevelCheck program uses a patient’s MRI or CT scan images taken before the operation. By feeding the imaging data into the Level Check computer program, engineers use mathematical algorithms to compare anatomical landmarks, line them up, and transfer the digital labels of each spinal segment from the preoperative scan to the digital X-ray taken in the operating room.” (Bartlett 2019).
Early studies of the LevelCheck algorithm (De Silva 2016) showed it to be helpful in 42.2% of cases (168/398), to improve confidence in 30.6% of cases (122/398), and in no case diminished performance (0/398), supporting its potential as an independent check and assistant to decision support in spine surgery. In a more recent exercise (Manbachi 2018), 5 surgeons were asked to label spine X-rays that had been specifically chosen because they were the most difficult to read and label. They performed the task in two ways: with LevelCheck assistance and without. The median localization error without assistance was 30.4%, due to the challenging nature of the cases. With LevelCheck, the median error was 2.4% and the surgeons found LevelCheck increased confidence in 91% of cases. The second part of the study was a clinical study involving 20 patients undergoing spine surgery. It demonstrated accuracy in all cases. The algorithm runtime varied from 17 to 72 seconds in its current implementation.
And, though it is not directly related to site markings, another facet of avoiding wrong site surgery is worth mentioning. A hospital in the UK recently had to formally ban using abbreviations for right and left after one patient had two procedures on the wrong site (Ord 2019). While we have included avoiding abbreviations like OD and OS and OU (instead writing out right eye and left eye and both eyes, respectively) or AD and AS and AU (instead writing out right ear and left ear and both ears, respectively), most “do not use” lists have not specifically commented on avoiding other abbreviations for “left” and “right”. But it probably also makes sense to write out “left” or “right” or “both” rather than using L or R or B (either alone or within a circle) as we often do. We’ve previously noted that such abbreviations on booking logs and forms can especially be problematic and should not be used (see our October 30, 2012 Patient Safety Tip of the Week “Surgical Scheduling Errors”). Indicating right or left or bilateral by using circles around an “R”, “L”, or “B” respectively is particularly dangerous in scheduling since it is very easy to mistake these for the wrong side, particularly on faxed forms (yes, unfortunately, surgical case scheduling still often relies on faxed forms!). You really shouldn’t use abbreviations at all on your booking forms. Similarly, you should not use acronyms on your scheduling forms since all parties may not understand those.
Some of our prior columns related to wrong-site surgery:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts Outside the OR”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
March 15, 2016 “Dental Patient Safety”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
July 19, 2016 “Infants and Wrong Site Surgery”
September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”
May 2017 “Another Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy of a Wrong Procedure”
June 2017 “Another Way to Verify Checklist Compliance”
March 26, 2019 “Patient Misidentification”
Some of our previous columns on the impact of abbreviations in healthcare:
March 12, 2007 “10x Overdoses”
June 12, 2007 “Medication-Related Issues in Ambulatory Surgery”
September 2007 “The Impact of Abbreviations on Patient Safety”
July 14, 2009 “Is Your “Do Not Use” Abbreviations List Adequate?”
April 2015 “Pediatric Dosing Unit Recommendations”
December 22, 2015 “The Alberta Abbreviation Safety Toolkit”
References:
TJC (The Joint Commission). Sentinel event statistics released for 2018. Joint Commission Online 2019; March 13, 2019
https://www.jointcommission.org/assets/1/23/JC_Online_March_13.pdf
TJC (The Joint Commission). Universal Protocol (poster)
https://www.jointcommission.org/assets/1/18/UP_Poster1.PDF
TJC (The Joint Commission). National Patient Safety Goals Effective January 2019. The Joint Commission 2018
https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf
CHA (Children’s Hospital Association). Wrong-site Surgeries/Procedures are Still Occurring When Site is Difficult to Mark. CHA Alert 2019; April 17, 2019
Norton E. Using an Alternative Site Marking Form to Comply With the Universal Protocol. AORN Journal 2011; 93(5): 600-606 First published: April 27, 2011
https://aornjournal.onlinelibrary.wiley.com/doi/abs/10.1016/j.aorn.2010.10.020
Minnesota Hospital Association. Safe Site Toolkit.
Minnesota Hospital Association. Site Marking Recommendations and Guidance. May 1, 2017
dental chart
https://www.mnhospitals.org/Portals/0/Documents/ptsafety/site/dental-chart.doc
CDPH (California Department of Public Health). Complaint Intake Number: CA00501908. CDPH 2018
Bartlett P. New Computer Program Reduces Spine Surgery Errors Linked to “Wrong Level” Labeling. Newswise Press Release 2019; February 6, 2019
De Silva T, Lo SL, Aygun N, et al. Utility of the LevelCheck Algorithm for Decision Support in Vertebral Localization. Spine (Phila Pa 1976); 2016 Oct 15
Manbachi A, De Silva T, Uneri A, et al. Clinical Translation of the LevelCheck Decision Support Algorithm for Target Localization in Spine Surgery. Ann Biomed Eng 2018; 10: 1548-1557. Epub 2018 Jul 26.
https://link.springer.com/article/10.1007%2Fs10439-018-2099-2
Ord C. Doctors banned from using abbreviations for 'left' and 'right' after medical mix-up. Oxford Mail 2019; May 4, 2019
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May 21, 2019
Mixed Message on Number of Open EMR Records
Over 10 years ago, when we were doing our first electronic medical record (EMR) implementation, we predicted that wrong patient errors would likely increase as EMR adoption became more widespread (see our May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”). One of the reasons we identified was the ability to have the record of more than one patient open simultaneously. Back then, the major problem was that multiple IT systems were not yet integrated. So, it was possible to have one patient record open on a CPOE system and that of another open in a separate lab IT system or radiology PACS system. But, even as EMR’s became more integrated, some systems allowed users to have open records of more than one patient at a time.
The Joint Commission (TJC 2015) and the Office of the National Coordinator for Health Information Technology (ONC 2016) have agreed with us and recommended that the number of open EMR records be restricted to one record.
A recent study by Adelman and colleagues, whose work we have referenced in so many of our columns, has challenged that concept. The researchers (Adelman 2019) took advantage of a rollout of a new EMR to randomize users to being restricted to one open record at a time vs being allowed to have as many as four records open simultaneously. They then used their RAR (Retract-and-Reorder) methodology (see our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE”) to identify instances where a user initially entered an order on the wrong patient. The RAR methodology is also nicely described in the supplement to the current Adelman study. It is a tool we’ve recommended you use in tracking and monitoring patient misidentification issues as part of your quality improvement program (see our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification”). The RAR methodology, of course, measures near misses (by definition, it identifies instances where the user recognized the error and corrected it). But it is one of the only proxies we have for assessing the frequency of potential wrong-patient ordering errors.
Overall, there was no significant difference in wrong-patient order sessions per 100,000 in the restricted vs unrestricted group, or in any setting. However, in the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, thereby limiting the power of the study to detect a treatment effect. Furthermore, when they did a post hoc analysis of order sessions in the unrestricted group, the number of wrong-patient order sessions completed with 1 record open was 52.0 per 100,000 order sessions, 132.0 per 100,000 with 2 records open, 165.7 per 100,000 with 3 records open, and 184.5 per 100,000 with 4 records open. Those results were also statistically significant.
The authors conclude that a strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. But they note that, since clinicians in the unrestricted group placed most orders with a single record open, the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors was limited.
In the accompanying editorial (Wachter 2019), Wachter et al. note there are confounders in this issue. One is that circumstances in which a user might want more than one record open are also ones that might engender errors. In complex healthcare environments workload and multitasking may be more important factors contributing to errors. They also remind us that we need to consider unintended consequences and look at the whole picture. An example they give is someone entering a complex heparin titration order who is interrupted for an urgent need for an analgesic on another patient. Closing one record, opening another, then reopening the first record could lead to errors that are not wrong-patient errors. Such tradeoffs between safety and efficiency have been a topic of many of our columns (see, for example, our Patient Safety Tip of the Week “ETTO’s: Efficiency-Thoroughness Trade-Offs”).
Both the Adelman researchers and the editorialists seem reassured that the trial had sufficient power to test the primary question of whether a restricted vs unrestricted configuration reduces wrong-patient orders and that the less restrictive approach (allowing multiple records to be open simultaneously) does not lead to an overall increase in wrong-patient orders.
We don’t agree. Most of the points made in the editorial are ones we do agree with and have often discussed in our columns. But the major problem with the Adelman study is akin to the argument we’ve made in the overlapping surgery debate: the sheer size of the data buries the important findings. The sheer volume of instances where only one record was open dilutes out the findings that occurred when multiple records were open. It is hard to ignore the post-hoc analysis that has what we consider to be the most important facet of this study. It clearly shows that there is an increase in wrong-patient orders when multiple records are open simultaneously and this phenomenon occurs in a dose-dependent fashion.
We hope the study does not open the door to widespread adoption of the less restrictive policy. And, if healthcare systems do start to allow multiple records to be open at the same time, they should incorporate the RAR methodology as part of their quality improvement activities to monitor and track for patient misidentification errors.
We hope you’ll go back to our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” to review the multitude of issues related to wrong-patient events and what you should be doing to reduce the risks of such events in your organizations.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Adelman JS, Applebaum JR, Schechter CB, et al. Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order ErrorsA Randomized Clinical Trial. JAMA 2019; 321(18): 1780-1787
https://jamanetwork.com/journals/jama/fullarticle/2733207
TJC (The Joint Commission). Safe use of health information technology. Sentinel Event Alert. Issue 54. March 31, 2015
https://www.jointcommission.org/assets/1/18/SEA_54.pdf
ONC (Office of the National Coordinator for Health Information Technology). Self-assessment: patient identification: general instructions for the SAFER Self-Assessment Guides. September 2016
https://www.healthit.gov/sites/default/files/safer/guides/safer_patient_identification.pdf
Wachter RM, Murray SG, Adler-Milstein J. Restricting the Number of Open Patient Records in the Electronic Health Record. Is the Record Half Open or Half Closed? JAMA 2019; 321(18): 1771-1773
https://jamanetwork.com/journals/jama/article-abstract/2733189
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May 28, 2019
The Older Physician
In our July 7, 2015 Patient Safety Tip of the Week “Medical Staff Risk Issues” one of the issues we discussed was “the aging physician”. This is often even more difficult a problem to deal with than the disruptive physician. This physician is usually a very well liked and respected physician who has practiced at the hospital and community for many years. But now his/her skill levels and perhaps cognitive capabilities have begun to decline. But he/she may not be aware of this decline and everyone is afraid to confront him/her about it. Most of his/her patients still love him/her and the board members are his/her friends or have long interacted with him/her in community activities.
In a few cases he/she wants to continue practicing because they need the income. More commonly they want to continue practicing because they love what they are doing and that is their whole life. They feel obligated to their patients and communities. Some don’t have outside interests and would not know how to exist without coming to the hospital.
In the “old days” these physicians would hang out in the medical staff lounge and be asked to serve as “assistant surgeons” (they didn’t have to actually be surgeons) on surgical cases. But third party payors have now largely eliminated fees for assistant surgeons in all but a few select surgical procedures. So that route for staying active in the hospital has disappeared.
You begin to hear whispers amongst staff about their concerns regarding this physician. They all know that sooner or later he/she is going to do something that might result in patient harm. But they are not willing to come forward with specific examples. Medical directors and medical executive committees are often handcuffed when no one is willing to formally come forward with negative information on such physicians.
There is a good chance your hospital bylaws have not included any verbiage about physician age since they don’t want to appear discriminatory. And it is extremely difficult to specify an age at which some sort of mandatory evaluation should be done. There are many physicians well in their 70’s who practice just fine and some in their 50’s whose skills have already deteriorated.
But there has been a lot of attention in the literature recently addressing the issue of the aging physician. The aging surgeon has probably received the most attention. For general surgeons, 46.4% are over the age of 55 (AAMC 2019). And the percentage over age 55 is greater than 50% for orthopedic, thoracic, urologic, and plastic surgeons. And surgeons in rural areas tend to be even older. So the problem is not only identifying who can perform safely but there is also a manpower issue to be dealt with in the future.
Complicating the issue are a couple recent studies on patient outcomes of older physicians. Tsugawa and colleagues (Tsugawa 2017), analyzing a sample of Medicare patients age 65 and older cared for by hospitalists, found that, within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.
But for surgeons, the same researchers (Tsugawa 2018) found that patients treated by older surgeons actually had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons. And, for eye surgeons performing cataract surgery, Campbell et al. (Campbell 2019) found that “late career” surgeons did not have more complications that eye surgeons earlier in their careers. That finding held up even when surgical volume was factored in.
So, age per se, cannot be the sole factor considered in decisions about the status of aging physicians. Katlic et al (Katlic 2019) note that “establishing a mandatory retirement age for surgeons would be a straightforward solution but would be illegal, inappropriate, and unfair because of the variability in function among older individuals of a given age”. There are a handful of occupations (eg. air traffic controllers) for which Congress has approved mandatory retirement age, but physicians are not one of them.
They note that some hospitals have adopted a Late Career Practitioner Policy in their medical staff bylaws. These hospitals may require physicians and advanced practice clinicians older than 70 years who apply for recredentialing to undergo physical examination, eye examination, and cognitive screening.
Katlic and Coleman previously described the elements of a formal Aging Surgeon Program (Katlic 2014). In both articles they described this as a more comprehensive option for surgeons identified either through screening or performance issues identified by medical staff. Their program is a 2-day, multidisciplinary, objective, and confidential evaluation of a surgeon's physical and cognitive function. It includes physical, neurologic, and ophthalmologic examinations, neuropsychological and physical/occupational therapy testing. A confidential report is then sent to the hospital medical staff that requested the evaluation. Based on the objective information provided in the report, the hospital medical staff may consider options such as continuing full privileges; no privileges; no operating privileges; operating privileges if assisted by another surgeon (routine vs only complex cases); assistant privileges only; focused review of cases (all vs certain number); or decreased work hours (eg, no on-call duties). Katlic et al do discuss surgical simulator testing but note that its validity for privileging issues has not yet been determined. (They also note that surgical simulator testing can be resource intensive, for both equipment and human time, and would need to be specialty specific.)
Weinacker (Weinacker 2018) described a Late Career Practitioner Policy that was implemented at Stanford Health Care (SHC). It uses focused physical exams and robust peer reviews to screen physicians. After turning 75, all physicians practicing at SHC must undergo physical exams and peer reviews every 2 years. She notes that age 75 was chosen somewhat arbitrarily, but the choice was guided by data that show the rate of decline of cognitive functions starts gradually as early as age 35 or 40 until about age 70 or 75, when deterioration begins to increase at a faster pace.
One issue we had not previously considered was the impact of employment status. As more and more healthcare organizations are employing physicians, they need to take into account the Age Discrimination in Employment Act. Weinacker notes that Act protects workers 40 years of age and older from being denied employment due to advancing age, but would not apply to physicians on staff who are not employed.
Because there were no data in the literature to support (or refute, for that matter) the use of cognitive screening to gauge a physician's ability to practice safely, Stanford Health Care dropped that requirement. Instead, they increased the number of peer reviews from 3 to 10, an approach that does have support in the literature. They ask the chief of surgery for names of 10 peers who are in a position to honestly and fairly judge a physician's ability to practice and include them in the peer review process.
Stanford Health Care does require physical exams. These can be performed by individuals' primary care physicians. The focus is on determining whether surgeons have the physical skills needed to perform the procedures for which they're privileged.
We have some concerns about who does the physical exam. We feel that having access to truly independent evaluations is critical. For one thing, the primary care physician may not fully understand the nature of the tasks performed by the individual physician being evaluated (especially when that physician is a surgeon). Second, physicians on your own hospital staff are often uncomfortable evaluating a medical staff colleague, knowing that their assessment may result in that physician losing privileges. Equally important in our litiginous society is the threat of a lawsuit by a physician who might lose his/her privileges. We’ve seen instances where such physicians have sued for restraint of trade when a colleague in the same specialty has made an adverse determination about a physician. Because of that latter threat it is often impossible to get such an assessment within the same city or geographic region.
Importantly, Weinacker notes that the evaluations are not pass/fail assessments. Rather, they are used to determine whether modifications might be done to help keep the physician in practice as long as possible. For example, they may find a way to accommodate a surgeon who has a physical ailment that interferes with ability to operate. This focus on maintaining respect was likely one reason they were able to adopt their policy.
And respecting and valuing surgeons as they age is a main focus of timely new guidance and recommendations recently proposed by the Society of Surgical Chairs (Rosengart 2019). They note the need for career transition discussions with surgeons beginning early in surgeons’ careers.
They note that there is great variability in the cognitive decline that takes place with aging, but also that clinical experience may offset declines in cognitive performance. As such, mandating retirement at a specific age would undoubtedly remove some competent surgeons from the workforce. But they also note that physicians’ self-awareness of cognitive decline often does not coincide with objective performance measures.
Specific actions they recommend include:
But the recommendations also include elements of performance assessment and privileges:
In our July 7, 2015 Patient Safety Tip of the Week “Medical Staff Risk Issues” we noted the AMA had voted to approve a report saying it is time to have a system for assessing the competence of older physicians but there was considerable sentiment expressed that screening physicians at a certain age “is inappropriate and smacks of ageism” (Frellick 2015). The AMA had not yet developed criteria or processes for such assessments. Subsequently, guiding principles for assessing the competency of senior/late career physicians were proposed by the AMA’s Council on Medical Education, but these were not adopted and the report was back to the Council on Medical Education (Firth 2018).
The American College of Surgeons did issue a Statement on the Aging Surgeon in 2016 (ACS 2016). While it was not in favor of a mandatory retirement age, it recommended that, starting at age 65 to 70, surgeons undergo voluntary and confidential baseline physical examination and visual testing by their personal physician for overall health assessment and regular interval reevaluation thereafter for those without identifiable issues on the index examination. It also encouraged surgeons to also voluntarily assess their neurocognitive function using confidential online tools. It also noted that voluntary self-disclosure of any concerning and validated findings is encouraged as part of a surgeon’s obligations. It also noted that colleagues and staff must be able to bring forward and freely express legitimate concerns about a surgeon’s performance and apparent age-related decline to group practice, departmental and medical staff, or hospital leadership without fear of retribution. It stressed the importance of peer-reviewed methods, including ongoing professional practice evaluation, as part of recredentialing and, if a potential issue is identified, additional methods of evaluation may include chart reviews, peer review of clinical decision making, 360-degree reviews and patient feedback, observation or video review of operating room cases, and proctoring.
It acknowledged that there will be occasions were a surgeon will need to be referred to a comprehensive evaluation program, conducted at a number of specialized centers where a battery of tests for neurocognitive function can be conducted in the form of a neuropsychological assessment (the costs of which should be borne by the hospital or medical staff, not the surgeon). But it emphasized that these results cannot be used in isolation to determine continuation or withholding of hospital and surgical privilege but should be incorporated as an additional piece of information.
A 2017 review of the issue (Dellinger 2017) had recommendations for multiple stakeholders. In addition to calling upon healthcare organizations to develop policies for mandatory testing at certain ages and do more peer observation of actual care, specialty societies to provide standards and resources, local medical societies to provide resources to test solo practitioners or rural providers, individual physicians to voluntarily submit to annual exams similar to aviation physical that pilots must take, and liability insurance companies to offer lower fees to those physicians who submit to those exams.
And what if you’re a patient? Family physician Jonathan Maltz, in a recent perspective in the Washington Post (Maltz 2019), had some good advice for patients to assess whether they should continue to be cared for by their aging physician. Be concerned if:
This issue of dealing with the aging physician is not going to go away. It’s going to become more prevalent as our clinicians themselves deal with difficult issues about their careers. We hope healthcare organizations will develop a Late Career Practitioner Policy that focuses on patient safety but deals with the issue in a prospective, respectful and compassionate way. Recommendations such as those from the Society of Surgical Chairs (Rosengart 2019). and Stanford Health Care’s Late Career Practitioner Policy (Weinacker 2018) are a good starting point. The concept of beginning the discussion with your clinicians long before they are “aging” needs to be ingrained in your programs. Resources such as the Aging Surgeon Program at Sinai Hospital/LifeBridge Health (developed by Katlic and others) may be very helpful to you once have reached an age where their skills and cognitive functions may start to wane.
References:
AAMC (Association of American Medical Colleges). 2018 Physician Specialty Data Report. AAMC 2019
https://www.aamc.org/data/workforce/reports/492536/2018-physician-specialty-data-report.html
Tsugawa Y, Newhouse JP, Zaslavsky AM, et al. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ 2017; 357: j1797 Published 16 May 2017
http://www.bmj.com/content/357/bmj.j1797
Tsugawa Y, Jena AB, Newhouse RL, et al. Age and sex of surgeons and mortality of older surgical patients: observational study. BMJ 2018; 361 Published 25 April 2018
https://www.bmj.com/content/361/bmj.k1343
Campbell RJ, el-Defrawy SR, Gill SS, et all Association of Cataract Surgical Outcomes With Late Surgeon Career StagesA Population-Based Cohort Study. JAMA Ophthalmol 2019; 137(1): 58-64
https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2706484
Katlic MR, Coleman J, Russell MM. Assessing the Performance of Aging Surgeons. JAMA 2019; 321(5): 449-450
https://jamanetwork.com/journals/jama/article-abstract/2721291
Katlic MR, Coleman J. The aging surgeon. Ann Surg 2014; 260(2): 199-201.
https://journals.lww.com/annalsofsurgery/fulltext/2014/08000/The_Aging_Surgeon.1.aspx
Weinacker A. Staffing: How Do You Deal With Aging Surgeons? Outpatient Surgery Magazine 2018; XIX(6): June 2018
Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon. Guidance and Recommendations From the Society of Surgical Chairs. JAMA Surg 2019; Published online May 15, 2019
https://jamanetwork.com/journals/jamasurgery/fullarticle/2733041
Frellick M. Screen Aging Physicians for Competency, Report Asks. Medscape Medical News June 15, 2015
http://www.medscape.com/viewarticle/846497
Firth S.How Can Competency be Measured in Older Docs? AMA council guidance for testing fails to win over delegates. MedPage Today 2018; November 14, 2018
https://www.medpagetoday.com/meetingcoverage/ama/76334
ACS (American College of Surgeons). Statement on the Aging Surgeon. January 1, 2016
https://www.facs.org/about-acs/statements/80-aging-surgeon
Dellinger EP, Pellegrini CA, Gallagher TH. The Aging Physician and the Medical Profession. A Review. JAMA Surg 2017; Published online July 19, 2017
http://jamanetwork.com/journals/jamasurgery/article-abstract/2644000
Maltz J. When should an aging doctor call it quits? Washington Post 2019; March 31, 2019
LifeBridge Health. Aging Surgeon Program
http://www.agingsurgeonprogram.com/AgingSurgeon/AgingSurgeon.aspx
Print “The Older Physician”
June 4, 2019
Medication Errors in the OR - Part 3
In our Patient Safety Tips of the Week for March 24, 2009 “Medication Errors in the OR” and November 3, 2015 “Medication Errors in the OR - Part 2” we discussed multiple reasons that medication errors are prone to occur in the OR. First, the OR is a complex environment where multiple disciplines interact on patients with complicated medical problems. Second, many of the medication safety tools we use elsewhere in healthcare are often not used in the OR. Specifically, one person (the anesthetist) is often responsible for ordering, dispensing, and administering medications. That bypasses the usual steps where at least 3 individuals (ordering clinician, pharmacist, and nurse) set eyes on a medication and have the opportunity to spot an error. And many OR’s still lack the other key medication safety tools, like CPOE and barcoding, that can help stop an error before it reaches the patient. Toss in the distractions and interruptions that frequently occur in the OR and “the perfect storm” is brewing.
In our Patient Safety Tip of the Week for November 3, 2015 “Medication Errors in the OR - Part 2” we noted a study showing medication errors in the perioperative setting are extremely common (Nanji 2015). In fact, one in every 20 perioperative medication administrations resulted in a medication error or adverse drug event. The overall rate of 5.3% is pretty close to the rates we typically see on inpatient units. And almost half of all surgery cases had at least one medication error or adverse drug event.
Since our last column on medication errors in the OR, there have been several reviews on the topic.
Wahr et al. (Wahr 2017) did a literature review and found 138 unique recommendations for OR medication safety, then used a modified Delphi process to whittle the list down to 35 specific recommendations. The authors note that, given the lack of randomized controlled studies to direct intraoperative medication safety strategies, definition of best practices must rely on expert opinion. Consensus statements regarding medication safety strategies have been published by multiple entities (ISMP, APSF, AORN) over the past two decades. We refer you to Table 4 in the Wahr review for the full list of the 35 recommendations. Most of them are covered in the recommendations listed below.
AORN (Association of periOperative Registered Nurses) has been a pioneer in addressing medication safety in the perioperative period. Boytim and Ulrich (Boytim 2018) conducted a systematic literature review of perioperative medication errors. They found that, in the OR, substitution, an incorrect dose, omission, and the wrong medication given accounted for more than 70% of MEs in eight of ten studies. Wrong route was also noted in many of the studies but wrong dosage form was seldom noted. Analgesics, antibiotics, and vasopressors had the highest incidence of medication errors across all perioperative areas.
Contributing factors included distraction, communication, haste, inattention, performance deficits, and knowledge deficits. Labeling mistakes and syringe swaps were the most common causes of substitution errors. Appearance of the vials and packaging often contributed. Environmental and workflow issues that contributed included transfers, fragmentation, change in providers, and an increase in workload. Length of surgery and emergency surgery were sometimes cited as contributing factors. Human factors that contributed included haste, stress, and pressure to proceed. Workarounds were also noted in some studies (see, for example, our April 5, 2016 Patient Safety Tip of the Week “Workarounds Overriding Safety”). As you’d expect, fatigue, distractions and interruptions were also noted as contributing factors. Of patient characteristics, higher level of acuity was often mentioned as increasing the likelihood of errors. And problems with medication reconciliation were also noted as contributing factors.
Suggested interventions included:
And Outpatient Surgery (a division of AORN, Inc.) has had several articles with solid recommendations to improve medication safety in the perioperative period (Novak 2015, Litman 2018, Sones 2019). To summarize some of the recommendations in these three articles:
A report from the PPSA (Pennsylvania Patient Safety Authority) analyzed over 1000 reports on perioperative medication errors in the Pennsylvania Patient Safety Reporting System (PA-PSRS) from 2017 (Cierniak 2018). 73% of the reports were from the intraoperative setting (the remaining 27% were from the post-anesthesia care units). Over half the errors reached the patient but only 1.6% resulted in patient harm. The PPSA notes that is a good “good catch” rate.
Types of error included:
Analgesics and antibiotics accounted for over 60% of the errors.
Many of the reports included information about factors contributing to the errors. Communication breakdowns were cited in 75% of the reports, and the medication ordering process was involved in just under half of those reports. Medication ordering issues were cited in 36.7% of all reports.
Transitions and handoffs contributed to many of the errors. For example, a second dose of a medication might be administered because the healthcare professionals were unaware the first dose had already been given. In other cases, a patient might be pre-medicated and sedated for a procedure at the wrong time, resulting in being sedated for longer than necessary. Documentation errors, which were present in 9.3% of cases with poor communication, often led to subsequent errors.
As we noted above, a major contributing problem is that one provider (the anesthetist) orders the drug, prepares it, and administers it. That bypasses many of the safety mechanisms involved in the medication process in other areas (no second set of eyes reviews the process). In the PPSA study, 29.3% of all reports involved issues that occurred while handling medications during preparing and administering (misprogramming of infusion pumps, medication mix-ups, and mislabeled, unlabeled, or otherwise unidentifiable medications, etc.). Problems programming smart infusion pumps were especially problematic (see our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems”). But sometimes the issues were related to things like line disconnects or pump malfunction during patient transfer.
Accidentally swapping one medication for another while a provider is handling several medications at one time either inside or outside the sterile field led to some medication mix-ups.
Improper storage of medications contributed to some errors. Many of these involved automated dispensing cabinets (ADC’s) and instances in which a medication was accidentally stocked or returned to the wrong pocket or bin in the ADC. See our January 1, 2019 Patient Safety Tip of the Week “More on Automated Dispensing Cabinet (ADC) Safety” for other issues related to ADC’s.
Container mix-ups and syringe swaps were cited as key vulnerabilities in an ISMP alert in 2015 (ISMP 2015). ISMP noted the anesthesia provider might accidentally pick up the wrong vial or ampule, especially if it looks similar to another container or is placed near another medication on the anesthesia tray or cart. For example, ISMP recently reported container mix-ups between VAZCULEP (phenylephrine) and BLOXIVERZ (neostigmine) by anesthesia providers.
They go on to discuss that, in many hospitals, most anesthesia syringes are prepared in the surgical suite by the anesthesia provider, When multiple syringes are prepared, it is possible for the anesthesia provider to inject from the wrong syringe (“syringe swapping”). ISMP found multiple cases of mix-ups between tranexamic acid and bupivacaine in which tranexamic acid was inadvertently administered via the intrathecal route of administration. In these cases, look-alike containers with the same volume of medication and red font print on the label contributed to the mistakes.
The latter mix-up is worth reiterating. Tranexamic acid is only used for a few procedures, so one would question why it would even be included in most OR setups. Don’t forget the mix-up we’ve pointed out several times where methylene blue dye was erroneously used in eye surgery instead of trypan blue (see our May 20, 2014 Patient Safety Tip of the Week “Ophthalmology: Blue Dye Mixup” and our September 2014 What's New in the Patient Safety World column “Another Blue Dye Eye Mixup”). There is little reason to keep methylene blue in most OR setups since it is used only in a few select instances.
Recommendations from PPSA and ISMP:
We also refer you back to our November 3, 2015 Patient Safety Tip of the Week “Medication Errors in the OR - Part 2” for a discussion about the Anesthesia Patient Safety Foundation’s video on medication safety in the operating room (APSF 2012), including the recommendation about the use of the “STPC” system:
S Standardization
T Technology
P Pharmacy/Prefilled/Premixed
C Culture
And a study just published (Black 2019) throws in yet another factor contributing to medication errors: calculation errors. The researchers administered a 15-question computational test to anesthesia residents and faculty at 7 academic institutions. Both groups committed a median value of 2 errors per test, for a mean error rate of 17.0%. The error rate for postgraduate year 2 residents was less than for postgraduate year. The error rate for faculty increased with years of experience. Error rates were independent of the number of hours of sleep. As you might expect, error rates varied with the number of operations needed to calculate the answer. The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty.
Some of our prior columns on medication errors in the OR:
March 24, 2009 “Medication Errors in the OR”
May 20, 2014 “Ophthalmology: Blue Dye Mixup”
September 2014 “Another Blue Dye Eye Mixup”
November 3, 2015 “Medication Errors in the OR - Part 2”
References:
Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology 2015; October 2015 Newly Published on 10 2015
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2466532
Wahr A, Abernathy JH, Lazarra EH. Medication safety in the operating room: literature and expert-based recommendations. British Journal of Anaesthesia 2017; 118 (1): 32-43
https://bjanaesthesia.org/article/S0007-0912(17)30113-7/fulltext
Boytim J, Ulrich B. Factors contributing to perioperative medication errors: A systematic literature review. AORN J 2018; 107(1): 91-107
https://aornjournal.onlinelibrary.wiley.com/doi/full/10.1002/aorn.12005
Novak R. Best Practices in Drug Safety. Expert advice on proper medication storage, security and labeling. Outpatient Surgery 2015; October 2015
Litman R. Tools to Improve Medication Safety. To eliminate administration mistakes, you have to eliminate the human factor. Outpatient Surgery 2018; July 2018
Sones S. Your Prescription for Medication Safety. Our pharmacy consultant dispenses indispensable advice. Outpatient Surgery 2019; XX No. 4; April 2019
Cierniak KH, Gaunt MJ, Grissinger M. Perioperative Medication Errors: Uncovering Risk from Behind the Drapes. Pa Patient Saf Advis 2018; 15(4).
http://patientsafety.pa.gov/ADVISORIES/Pages/201812_Perioperative.aspx
ISMP (Institute for Safe Medication Practices). Key vulnerabilities in the surgical environment: Container mix-ups and syringe swaps. ISMP Medication Safety Alert! Acute Care Edition 2015; November 5, 2015
http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=123
APSF (Anesthesia Patient Safety Foundation). Medication Safety in the Operating Room: Time for a New Paradigm. January 2012
http://apsf.org/resources/med-safety/
Black S, Lerman J, Banks SE, et al. Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors. Anesthesia & Analgesia 2019; 128(6): 1292-1299
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June 11, 2019
ISMP's Grissinger on Overreliance on Technology
The recent crashes of the Boeing 737 Max8 aircraft brought to the attention of all some of the downsides of technology, including both “automation surprises” and overreliance of technology. The same issues occur in health care. Several of our recent columns have had examples (see our Patient Safety Tips of the Week for December 11, 2018 “Another NMBA Accident”, January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”, and February 5, 2019 “Flaws in Our Medication Safety Technologies”).
But we discussed the issue of overreliance on technology in detail in our August 23, 2016 Patient Safety Tip of the Week “ISMP Canada: Automation Bias and Automation Complacency”.
This month, ISMP’s Matthew Grissinger used the same index incident from the 2016 ISMP Canada bulletin (ISMP Canada 2016) as a springboard for a good discussion in the journal P&T on overreliance on technology, automation bias, and automation complacency (Grissinger 2019). The incident occurred in a patient admitted with new onset seizures. An order for phenytoin was handwritten using the brand name Dilantin. A hospital pharmacy staff member, who was relatively new to the clinical area, entered the first 3 letters “DIL” into the pharmacy IT system. The staff member was then interrupted and, when the task was resumed, diltiazem 300 mg was ordered instead of Dilantin 300 mg. Back on the clinical unit the handwritten order had correctly been transcribed by a nurse into the MAR. Later, when another nurse obtained the evening’s medications for the patient from the ADC (automated dispensing cabinet), he/she noted a discrepancy between the MAR and the ADC display but accepted the information on the ADC display as being correct. The diltiazem was erroneously administered and the patient developed significant hypotension and bradycardia.
First, the definitions:
Automation bias is “the tendency to favor or give greater credence to information supplied by technology (e.g., an ADC display) and to ignore a manual source of information that provides contradictory information (e.g., a handwritten entry on the computer-generated MAR), even if it is correct.”
Automation complacency, a closely linked, overlapping concept “refers to the monitoring of technology with less frequency or vigilance because of a lower suspicion of error and a stronger belief in its accuracy.”
Grissinger gives the example of a nurse who relies on the ADC display that lists the medications to be administered might forget or ignore that information from the device may depend on data entered by a person. In fact, we gave such an example in our August 23, 2016 Patient Safety Tip of the Week “ISMP Canada: Automation Bias and Automation Complacency”. That was an incident that was a near-miss involving insulin. A physician, from a specialty not used to ordering insulin, did medication reconciliation and mistook the “U-100” formulation of insulin listed on records accompanying the patient to be a dose of 100 units of insulin. The physician entered a dose of 100 units of regular insulin into the CPOE system. The pharmacy system did not have dose range limits for insulin and there was no prompt for special review by the pharmacist. The nurse who received the syringe with 100 units of regular insulin was somewhat surprised by the relatively high dose but barcoded the patient’s wrist band ID and the medication and looked at the electronic MAR, all of which indicated correct patient, correct medication, correct dose. So, the medication was administered. Fortunately, because the nurse had an “uneasy feeling” she went back and checked the patient’s records and found that he had been on 10 units of regular insulin prior to admission. She drew a stat blood glucose level and administered D50W and potentially serious harm was prevented. In the old days, of course, a nurse would have immediately checked the records and the orders and spoken to the ordering physician before administering such a high dose of insulin. But, here, our tendency to believe that the technology is always correct biased the nurse toward first administering the insulin then checking further rather than checking further before administering it.
Two of the commonest cognitive biases that often lead to error are interrelated: confirmation bias and ignoring disconfirming information (see our September 28, 2010 Patient Safety Tip of the Week “Diagnostic Error”). Automation bias or overreliance on technology happen to be very strong contributors to confirmation bias. In the case described by Grissinger, the nurse trusted the ADC display rather than the handwritten entry on the computer-generated MAR.
Grissinger cites work of Kate Goddard and colleagues that noted clinicians overrode their own correct decisions in favor of erroneous advice from technology between 6% and 11% of the time (Goddard 2012) and the risk of an incorrect decision increased by 26% if the technology output was in error (Goddard 2014).
In a simulation exercise (Goddard 2014), clinicians were shown 20 hypothetical prescribing scenarios. They were asked to prescribe for each case, followed by being shown simulated advice that may have been correct or incorrect. Participants were then asked whether they wished to change their prescription, and the post-advice prescription was recorded. While CDSS advice improved the decision accuracy in 13.1% of prescribing cases, decision switches from correct pre-advice to incorrect post-advice occurred in 5.2% of all cases. The latter, of course, is a measure of automation bias.
Grissinger reiterates the 3 human factors in the ISMP Canada bulletin that contribute to automation bias and automation complacency:
1) our tendency to select the pathway with the least cognitive effort
2) our perception that the analytic capability of automated aids is superior to humans
3) we often “shed” our responsibility when an automated system is performing the same function.
He also notes that one’s experience may contribute, but possibly in different ways. For example, as our experience makes us more confident in our decisions, we may rely less on technology. But, on the other hand, we often become desensitized as we gain experience with the technology and ignore our instincts and go with the technology, particularly when we have developed trust in the reliability of a specific technology.
Grissinger offers several recommendations to reduce the risks of overreliance on technology, many of which were in the original ISMP Canada paper:
Analyze and address vulnerabilities. He suggests you do a FMEA (failure mode and effects analysis) for new technologies before undertaking facility-wide implementation. Also, encourage the reporting of technology-associated risks, issues, and errors.
Limit human-computer interfaces. Organizations should continue to enable the seamless communication of all technology, thereby limiting the need for human interaction with the technology, which could introduce errors.
Design technology to reduce over-reliance. He provides the good example in which current systems that allow a drug name to pop up after typing in just the first few letters of the drug name often result in selection of the first name to appear. He notes that requiring four letters to generate a list of potential drug names could reduce this type of error.
Provide training. Provide training in the technology involved in the medication use system to all staff who utilize the technology. Include information about its limitations, as well as previously identified gaps and opportunities for error. Importantly, he recommends you allow trainees to experience automation failures during training. For example, you might include instances of non-issue of an important alert; discrepancies between technology and handwritten entries in which the handwritten ones are correct; “auto-fill” or “auto-correct” errors; incorrect calculation of body surface area due to human error by inputting weight in pounds instead of kilograms, etc..
Reduce task distraction. He notes that automation failures are less likely to be identified if users are multitasking or are otherwise distracted or rushed.
In the “old” days (before CPOE and BCMA), after a physician wrote an order for a medication, a nurse would typically do a “mental approximation” to assess whether the dose ordered was in a reasonable range. We’ve seen more and more that now the response is simply to rely upon the IT systems and forego that mental approximation, losing an important extra check in the medication administration system. We’ve also described that mental approximation as an important step in managing home infusion (see our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems”). For example, if you are setting up an infusion of a chemotherapy agent that could be lethal if the total dose was administered over a few hours rather than several days as intended, you do a simple calculation in your head that would say “this infusion is going to be done in 4 hours”, not in the 4 days that were intended”. (Of course, if you are a regular reader of our columns, you’ll recognize we would tell you to never hang up an amount of medication that could be fatal if infused too rapidly!).
In our August 23, 2016 Patient Safety Tip of the Week “ISMP Canada: Automation Bias and Automation Complacency” we also discussed the aviation safety concept “automation surprise”. That refers to the fact that many complex computerized aviation systems may have the aircraft flying in a mode that is relatively masked to the pilot. For example, an aircraft may be flying under autopilot and if the autopilot disengages the pilot may not immediately be aware of several important flight parameters. There are numerous instances in the NTSB files about automation surprises contributing to aviation crashes.
Reports to NASA’s Aviation Safety Reporting System also provide examples of how attention to autoflight can lead to loss of situational awareness (NASA 2013). In examples, awareness of the aircraft’s actual flight path seems to have been compromised by:
In our January 7, 2014 Patient Safety Tip of the Week “Lessons From the Asiana Flight 214 Crash” we noted that one of the major issues contributing to this crash was apparently overreliance on technology. The pilots apparently thought that the automatic throttle system was engaged, which should have increased engine thrust when the airplane speed fell below the recommended speed. However, that automatic throttle system was not engaged. Once the pilots recognized that their speed and altitude were too low and that the autothrottle had not automatically increased speed, they tried to initiate a “go round” (i.e. to abort the landing and fly around and try again) but it was too late. It’s pretty clear that sometimes pilots don’t understand what mode the computer systems are in. The FAA released a comprehensive study on the overreliance of pilots on automation and loss of situational awareness due to automation surprises (FAA 2013).
The recent Boeing 737 MAX8 crashes also illustrate overreliance on technology – but this time on the manufacturer side. Boeing had put in place a software system designed to prevent the type of aerodynamic stalls noted above. It was intended to automatically force the plane’s nose down if a stall seemed imminent. The trigger for the software program was input from an “angle of attack” sensor. Apparently, in the crashes, that sensor was faulty and there was no second or backup sensor in place. When the software program triggered and forced the plane’s nose down, the pilots apparently did not know they had to manually disconnect that system. So, Boeing overrelied on technology to develop what it thought was a fix to a human problem. The unintended consequence was that it led to an “automation surprise” for the pilots.
Recently, we were test driving a new car that had a “smart” cruise control system, designed to slow down the vehicle as it neared the vehicle ahead. The car salesmen said “Go ahead and follow that car. This car will slow down and stop when he gets to the next stop sign.” Well, the road happened to curve just before that next stop sign. As the vehicle ahead turned at the curve first, our vehicle’s “smart” system lost sight of it and sped up! Fortunately, we had not yet developed trust in the new technology and were ready with our foot on the brake to avoid a collision. But we suspect that, once we had come to trust and rely on that technology, we may not have been so lucky.
So, overreliance on technology occurs in our daily lives and in many industries. Healthcare is no different. We often use computer systems in which multiple “modes” are available and we may not recognize which mode the system is operating in. Automation surprises can also occur in healthcare and, when coupled with automation bias, lead to serious adverse consequences. For example, if the computer is expecting a patient weight to be input in kilograms and someone instead inputs a weight in pounds, serious harm may be done to the patient. Or, if an infusion pump is expecting input of dose or dose rate instead of flow rate or vice versa (so called “wrong-field programming error”), major adverse consequences may occur. Also, in all our discussions about alarm issues we note that erroneous assumptions are often made that an alarm will trigger when anything serious happens, not realizing that the alarm parameters had been set to different physiologic parameters.
The bottom line: we all likely have some degree of automation bias and automation complacency in both healthcare and our other daily activities. We still need to use common sense and never assume that the technology is flawless. In our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!” we noted that we all should really look at each thing we are doing in patient care and think “could what I am about to do harm this patient?”.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
ISMP Canada. Understanding Human Over-reliance on Technology. ISMP Canada Safety Bulletin 2016; 16(5): 1-4
https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-05_technology.pdf
Grissinger M. Understanding Human Over-Reliance On Technology. P&T 2019; 44(6): 320-321, 375
Goddard K, Roudsari A, Wyatt JC. Automation bias: a systematic review of frequency, effect mediators, and mitigators. J Am Med Inform Assoc 2012; 19(1): 121-127 Published online June 16, 2011
https://academic.oup.com/jamia/article/19/1/121/732254
Goddard K, Roudsari A, Wyatt JC. Automation bias: empirical results assessing influencing factors. Int J Med Inform 2014 ;83(5): 368-375 Published online January 17, 2014
https://www.sciencedirect.com/science/article/pii/S1386505614000148?via%3Dihub
NASA. Autoflight Associated Loss of Situational Awareness. Callback 2013; 407: 1-2 December 2013
http://asrs.arc.nasa.gov/publications/callback/cb_407.html
FAA. Operational Use of Flight Path Management Systems. FAA September 5, 2013
http://media.nbcbayarea.com/documents/FAA_Final_Report_Recommendations+11-22-13.pdf
Print “ISMP’s Grissinger on Overreliance on Technology”
June 18, 2019
Found Dead in a Bed
A year ago, the Kansas City Star ran a story on “Dead in bed” (Marso 2018). The story begins with description of an 80 year old patient who had been admitted with a partial intestinal obstruction, apparently managed nonsurgically, who was now improving. The patient was scheduled for discharge the next day. Family mentioned she would fall asleep frequently while watching TV in the hospital but otherwise seemed returning to her usual self. The patient did not survive the night. She was found dead in bed. An autopsy was inconclusive for a cause of death, but no toxicology was done. Experts who reviewed the medical record commented that the doses and cumulative dosage of Dilaudid she had been receiving were quite high for an opioid-naïve elderly patient.
Retrospectively, her family also had noted her speech at times was slurred and mumbling during the hospital stay and, when she went to the bathroom, she seemed dizzy and unsteady on her feet.
The article goes on to discuss with anesthesiologist Frank Overdyk, a leading voice in the movement for continuous monitoring to avert opioid-induced respiratory depression (OIRD), the need for continuous electronic monitoring tools that include pulse oximeters and capnography. Overdyk noted that hospitals often use these in ICU’s but that only about 20 to 25 percent of hospitals have the capacity to use them at every bed and only about 1 percent do. The main reason, he said, is cost.
Speaking of Dilaudid, don’t get us started! See our series of columns on the dangers of Dilaudid/HYDROmorphone listed below:
Khanna et al. (Khanna 2019) note that nearly half of in-hospital cardiorespiratory arrests occur on general care floors. Opioid-induced respiratory depression is one of the possible causes in many cases. Overdyk was a key researcher in the recently reported PRODIGY (Prediction of Opioid-induced respiratory Depression In patients monitoried by capnoGraphY) trial (Khanna 2019), a prospective study in 16 international sites. Subjects on general care floors who were receiving opioids had continuous monitoring of cardiorespiratory parameters, including heart rate, oxygen saturation, end-tidal CO2, and respiratory rate. Respiratory depression occurred in 41.4% of over 1000 patients. Predictors of respiratory depression were: age ≥70 to <80 or ≥80, male sex, major organ failure, chronic heart failure or cardiac disease, coronary artery disease, COPD or pulmonary disease, pneumonia, type II diabetes, hypertension, kidney failure and opioid naivety. Interestingly, negative predictors were BMI ≥35 and asthma.
The researchers were able to use a multivariate regression model to develop an OIRD risk prediction tool using age 70-79 or 80 and older, male sex, sleep disorders, hypertension, and opioid naivety. They termed this the PRODIGY score. This tool had high accuracy, using multiple measures of accuracy.
PRODIGY score ranged from 0 to 39, with low risk between 0 and 7, intermediate risk between 8 and 15 and high risk more than 15.
Khanna, the lead author of the PRODIGY trial report, notes in a video presentation that patients suffering cardiorespiratory arrest on general care floors have a much higher mortality than those who are continuously monitored, such as those in an ICU setting. 46% of patients in the PRODIGY study suffered at least one episode of respiratory depression. He notes that this frequency is almost double what prior studies had found. Why? Because PRODIGY used continuous monitoring. Most previous studies used episodic monitoring. Five variables were strongly related to the risk of respiratory depression: age > 60, male sex, presence of sleep disordered breathing, opioid naivety, and chronic heart failure. These were incorporated into the PRODIGY risk prediction score. High risk patients had a risk score of more than 15, low risk less than 8, and intermediate risk 8 to 15. He notes that all 3 risk categories had significant intergroup variation, so that intermediate risk was significantly greater than low risk and high risk significantly higher than intermediate risk.
Bradford Winters, M.D., discussed the challenges of recognizing clinical deterioration in patients outside the intensive care unit and notes the importance of early warning systems and continuous physiological monitoring in identifying such deterioration (Winters 2018). He discusses the evolution of Rapid Response Systems (RRS) and describes that such have both an afferent and an efferent limb. He goes on to describe the variety of early warning systems (EWS) developed over the years and has a great table of all those EWS’s. But he notes a number of explanations as to why they generally failed to improve clinical outcomes.
Winters notes that surveillance monitoring may be a better way to collect and act on clinical data for a patient who is deteriorating on a general ward, but needs to overcome several challenging hurdles:
1) It needs to be mobile and wireless since general ward patients are usually ambulatory as compared to monitoring of ICU patients.
2) The mobile surveillance monitor must have adequate battery life.
3) The monitor needs to be comfortable and relatively unobtrusive.
4) The vital sign data collection should be continuous, since use of intermittently collected data may miss early signs of deterioration.
5) It needs to have an acceptable accuracy and a manageable false alarm rate.
Winters notes that studies of surveillance monitoring are still limited but the results are encouraging.
Verillo et al. (Verrillo 2019) compared continuous physiological monitoring to the current standard of clinical monitoring in patients admitted to a surgical unit. Continuous monitoring resulted in a statistically significant 27% decrease in the complication rate, and a clinically significant decrease in transfers to an intensive care unit and failure-to-rescue (FTR) events rate.
Opioid-induced respiratory depression, of course, has been the topic of many of our columns (see the full list below). The lack of continuous monitoring and, in particular, the infrequent use of capnography have been major impediments to identifying patients at risk for respiratory depression. Hopefully, future studies will demonstrate that use of the PRODIGY score and continuous physiological monitoring do result in improved clinical outcomes.
Of course, this all needs to be balanced against the risk of alarm fatigue. In our many columns on alarm fatigue we have stressed that alarms should alert healthcare professionals to clinically relevant conditions and that monitoring should be focused on those at risk and only for specified periods of time. For example, we’ve often noted that hospitals should avoid using telemetry outside accepted guidelines. Our hope is that risk assessment tools like the PRODIGY score will identify specific patients at risk so that continuous monitoring is not applied to all patients on a care unit, but rather selectively to those who truly need it.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
Some of our other columns on MEWS or recognition of clinical deterioration:
Our other columns on rapid response teams:
References:
Marso A. 'Dead in bed' common term in hospitals. Here's why patients should know about it. Kansas City Star 2018; March 15, 2018
http://www.kansascity.com/news/business/health-care/article203189944.html
Khanna A, Buhre W, Saager L, et al. Derivation And Validation Of A Novel Opioid-Induced Respiratory Depression Risk Prediction Tool (Abstract 36). Society of Critical Care Medicine 48th Critical Care Congress San Diego, California February 17–20, 2019; Critical Care Medicine 2019; 47(1): 18, January 2019
Video by Khanna
Khanna A. Pulmonology Consultant. Ashish Khanna, MD, on the PRODIGY Trial and Risk Score. Consultant360 2019;
Winters BD. Early Warning Systems: “Found Dead in Bed” Should be a Never Event. APSF Newsletter 2018; 33(2): 35-37
https://www.apsf.org/article/early-warning-systems-found-dead-in-bed-should-be-a-never-event/
Verrillo SC, Cvach M, Hudson KW, et al. Using Continuous Vital Sign Monitoring to Detect Early Deterioration in Adult Postoperative Inpatients. Journal of Nursing Care Quality 2019; 34(2): 107-113
Print “Found Dead in a Bed”
June 25, 2019
Found Dead in a Bed - Part 2
Last week’s Patient Safety Tip of the Week “Found Dead in a Bed” focused on opioid-induced respiratory depression (OIRD) and the need for continuous physiological monitoring in patients at risk for OIRD. But not all instances of sudden, unexpected death in hospitals are due to OIRD.
Over the years, in our investigations and root cause analyses of cases of sudden unexpected death on general care floors, we’ve sometimes come across cases where we suspect Torsade de Pointes (TdP) as the underlying mechanism. Autopsy fails to demonstrate an obvious cause of death, so we often presume a cardiac arrhythmia likely led to death. Because such patients were not on continuous monitoring, we cannot be sure that torsade de pointes was the actual cause of death. However, we’ve seen prolongation of the QTc interval that suggests torsade as a potential cause. And, it is important to recognize these cases because this lethal arrhythmia is potentially preventable.
Torsade de pointes is a form of ventricular tachycardia, often fatal, in which the QRS complexes become “twisted” (changing in amplitude and morphology) but is best known for its occurrence in patients with long QT intervals. (See our earlier columns on the several methods of measuring the QT interval and criteria for QTc prolongation). Though cases of the long QT interval syndrome (LQTS) may be congenital, many are acquired and due to a variety of drugs that we prescribe. The syndrome is more common in females and many have a genetic predisposition. And there are a number of reasons why this syndrome is more likely to both occur and result in death in hospitalized patients. Hospitalized patients have a whole host of other factors that may help precipitate malignant arrhythmias in vulnerable patients. They tend to have underlying heart disease, electrolyte abnormalities (eg. hypokalemia, hypomagnesemia, hypocalcemia), renal or hepatic impairment, and bradycardia, all of which may be precipitating factors. COPD was also recently added to the list of conditions associated with prolongation of the QTc interval, independent of electrolyte levels, comorbidities, or relevant medications (Zilberman-Itskovich 2019). More importantly, hospitalized patients may have the sorts of conditions for which we prescribe the drugs that are primarily responsible for prolonging the QT interval (eg. haloperidol, antiarrhythmic agents, etc.). And many of those drugs are given intravenously and in high doses in the hospital as compared to the outpatient arena. Rapid intravenous infusion of such drugs may be more likely to precipitate TdP than slow infusion.
Drugs commonly associated with torsade de pointes are haloperidol, methadone, thioridazine, amiodarone, quinidine, sotalol, procainamide, erythromycin, azithromycin, the antihistamine terfenadine and certain antifungals. But the list has grown by leaps and bounds in recent years. For a full list of drugs that commonly cause prolongation of the QT interval and may lead to Torsade de Pointes, go to the CredibleMeds® website. That extremely valuable site provides frequent updates when new information becomes available about drugs that may prolong the QT interval.
But one matter of real concern is prolongation of the QT interval by combinations of drugs. Our October 10, 2017 Patient Safety Tip of the Week “More on Torsade de Pointes” discussed an FDA warning (FDA 2016) about the commonly used anti-diarrheal loperamide (Imodium and numerous OTC formulations) as a possible cause of unexplained cardiac events including QT interval prolongation, Torsade de Pointes or other ventricular arrhythmias, syncope, and cardiac arrest. Apparently, the majority of reported serious heart problems occurred in individuals who were intentionally misusing and abusing high doses of loperamide in attempts to self-treat opioid withdrawal symptoms or to achieve a feeling of euphoria. “In cases of abuse, individuals often use other drugs together with loperamide in attempts to increase its absorption and penetration across the blood-brain barrier, inhibit loperamide metabolism, and enhance its euphoric effects.” The FDA lists the following drugs (noting the list is incomplete) as commonly interacting with loperamide: cimetidine, ranitidine, clarithromycin, erythromycin, gemfibrozil, quinidine, quinine, ritonavir, itraconazole and ketoconazole. Another study (Cook 2017) noted QTc prolongation related to an interaction between antifungal azoles and amiodarone. Another study (Lorberbaum 2016) noted that the combination of ceftriaxone (a cephalosporin antibiotic) and lansoprazole (a proton-pump inhibitor) will prolong the QT interval.
Several chemotherapeutic agents are known to prolong the QT interval, which can increase the risk of torsade de pointes (Zukkoor 2018). The most common are those of the tyrosine kinase inhibitor drug class, with vandetanib carrying the highest risk. And many chemotherapy regimens comprise of a number of supportive agents (eg. antiemetics, antidepressants, antihistamines, antibiotics) that may prolong the QT interval. The authors also note that other factors predisposing to QT interval prolongation are commonly seen in oncologic patients. For example, hypomagnesemia and hypokalemia due to poor oral intake or GI losses, elderly age, and impaired renal function are common in oncologic patients. And those with pre-existing cardiac disease are also more susceptible and may be on concomitant cardiac medications that potentiate QT prolongation and increase risk of torsade de pointes.
And don’t forget that it’s not just prescription and OTC drugs that may prolong the QT interval. Recent reports have focused on high volumes of energy drinks (Shah 2019) and grapefruit juice (Chorin 2019) as contributing to prolonged QTc intervals.
Tisdale et al. (Tisdale 2013) derived and validated a scoring system to predict QT interval prolongation in hospitalized patients, potentially identifying patients at risk for Torsade de Pointes. The Tisdale score could potentially be used to inform decisions about patient monitoring and/or treatment. For example, just as we discussed in our June 11, 2019 Patient Safety Tip of the Week “Found Dead in a Bed” using the PRODIGY score to identify which patients at risk for OIRD (opioid-induced respiratory depression) should receive continuous physiological monitoring, you might use the Tisdale score to identify which patients at risk for Torsade de Pointes should receive monitoring.
The major risk factors for Torsade de Pointes are potentially modifiable. Since the electrolyte disturbances may be corrected and medications may be switched there is significant opportunity to reduce the risk of torsade de pointes when prolonged QTc intervals are recognized early. But it’s pretty clear that it is beyond the capacity of the human brain to remember not only all the individual drugs that may prolong the QT interval but also all the drug-drug combinations that increase the risk. Add to that a general unawareness of the risks for Torsade de Pointes. So, we really need to rely upon technology to help us. Clinical decision support systems (CDSS) are the logical answer.
In our June 10, 2014 Patient Safety Tip of the Week “Another Clinical Decision Support Tool to Avoid Torsade de Pointes” we discussed another study by Tisdale et al. (Tisdale 2014) which demonstrated that use of CDSS (clinical decision support systems) and computerized alerts can reduce the risk of QT interval prolongation. One of the most important considerations is developing a system in which the risk of alert fatigue is minimized. We know from multiple studies done in the past that physicians override over 90% of computer alerts during CPOE (computerized physician order entry). To minimize the risk of alert fatigue and still accomplish your goal of reducing the risk to patients it is important to (1) deliver the alert to the right person (2) deliver alerts only for the most potentially serious events and (3) provide alternative options for the physician’s response.
They system developed and implemented by Tisdale and colleagues did all three. First, the alerts first went to the pharmacist, who would then evaluate the situation and decide whether discussion with and recommendations for the physician were appropriate. Second, the thresholds to trigger the alerts were set at levels expected to minimize alert fatigue. And, third, the pharmacist responding to the alert would present the physician with some options for actions.
Their system would trigger an alert when the QTc interval was >500 ms or there was an increase in QTc of ≥60 ms from baseline. Their system also identified through the electronic medical record multiple other conditions or laboratory results that identified patients at higher risk for QT interval prolongation.
After implementation of the CDSS system they found a significant reduction in the risk of QT prolongation (odds ratio 0.65). In addition, they found a significant reduction in the prescription of non-cardiac drugs known to prolong the QT interval (especially fluoroquinolone antibiotics and intravenous haloperidol). Overall, 82% of alerts were overridden. That still compares favorably to the frequency with which other alerts are overridden. Most of the overrides were for cardiac drugs (eg. amiodarone or other anti-arrhythmic drugs). The authors point out that overriding the computer alert did not mean that nothing was done. For example, even though the order for the drug may have been overridden, the pharmacist and physician may have modified some other risk factor (eg. corrected an electrolyte disturbance or stopped another medication) or increased the frequency of QTc surveillance.
In our April 9, 2013 Patient Safety Tip of the Week “Mayo Clinic System Alerts for QT Interval Prolongation” we discussed another CDSS tool that had been implemented at the Mayo Clinic (Haugaa 2013). In November 2010 the Mayo Clinic developed and implemented a system-wide QT alert system, called the pro-QTc system (see the prior column or the Haugaa article itself for details of the pro-QTc formula and scoring system). With some variation based on factors such as heart rate, a corrected QT interval (QTc) 500 msec or greater would trigger a notification alert to the ordering physician as a “semi-urgent finding” with a link to a Mayo website with guidance on management of such cases. They sent alerts to clinicians regarding about 2% of patients. For the population as a whole the QTc was a significant predictor of mortality. For each 10 msec increment in QTc there as a 13% increase in mortality, independent of age and sex. The pro-QTc score was also a significant predictor of death and did so in a “dose-dependent” manner (i.e. each one-point increment in the pro-QTc score further increased mortality by a factor of 17%). On multivariable analysis only the number of QT-prolonging medications and electrolyte abnormalities were significant independent predictors of death. This again emphasizes the importance of recognizing drug combinations that may contribute to QT prolongation.
A couple reviews (BMJ 2016, Li 2017) have discussed management issues in patients who have developed QTc prolongation, including discontinuation of the offending agent, consideration of alternate pharmacotherapy, assessment of the patient for any potential drug interactions that could lead to drug-induced QT prolongation, and evaluation for electrolyte abnormalities. They note an external defibrillator should always be readily available. Electrolyte abnormalities should be addressed. If the patient’s potassium is
low, it should be corrected. Magnesium sulfate should also be administered. The review by Li and Ramos (Li 2017) discusses the nuances of magnesium administration. It also discusses issues related to defibrillation if TdP actually occurs and use of temporary pacing, etc. while awaiting implantation of an automatic implantable cardioverter-defibrillator plus other special circumstances. The BMJ review (BMJ 2016) has a good discussion about when and how often to get EKG’s when prescribing medications that may prolong the QTc in patients at risk.
So, we’d like to reiterate points from our earlier columns on what your hospital or healthcare organization should be doing to reduce the risk you’ll find a patient “dead in a bed” from torsade de pointes:
Torsade de pointes is a relatively uncommon cause of sudden unexpected death but one that is potentially preventable. Being aware of the risk factors and having systems that identify when potentially dangerous drugs are being given to at-risk patients may potentially save lives.
Some of our prior columns on QT interval prolongation and Torsade de Pointes:
June 29, 2010 “Torsade de Pointes: Are Your Patients At Risk?”
February 5, 2013 “Antidepressants and QT Interval Prolongation”
April 9, 2013 “Mayo Clinic System Alerts for QT Interval Prolongation”
June 10, 2014 “Another Clinical Decision Support Tool to Avoid Torsade de Pointes”
April 2015 “Anesthesia and QTc Prolongation”
October 10, 2017 “More on Torsade de Pointes”
References:
Zilberman-Itskovich S, Rahamim E, Tsiporin-Havatinsky F, et al. Long QT and death in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease is not related to electrolyte disorders. International Journal of Chronic Obstructive Pulmonary Disease 2019; 14: 1053-1061 May 20, 2019
CredibleMeds® website
FDA (US Food and Drug Administration). FDA Drug Safety Communication: FDA warns about serious heart problems with high doses of the antidiarrheal medicine loperamide (Imodium), including from abuse and misuse. FDA Safety Announcement June 7, 2016
http://www.fda.gov/Drugs/DrugSafety/ucm504617.htm
Cook K, Sraubol T, Bova K, et al. QTc Prolongation in Patients Receiving Triazoles and Amiodarone. IDWeek 2017 Poster 173
As discussed in:
Han DH. QTc Prolongation With Concomitant Amiodarone, Azoles Examined. MPR 2017; October 6, 2017
Lorberbaum T. Sampson KJ, Chang JB, et al. Coupling Data Mining and Laboratory Experiments to Discover Drug Interactions Causing QT Prolongation. J Am Coll Cardiol 2016; 68(16): 1756-1764
http://content.onlinejacc.org/article.aspx?articleID=2565914
Zukkoor S, Thohan V. Drug-Drug Interactions of Common Cardiac Medications and Chemotherapeutic Agents. ACC (American College of Cardiology) 2018; December 21, 2018
Shah SA, Szeto AH, Farewell R, et al. Impact of High Volume Energy Drink Consumption on Electrocardiographic and Blood Pressure Parameters: A Randomized Trial. J Amer Heart Assoc 2019; Originally published4 Jun 2019
https://www.ahajournals.org/doi/full/10.1161/JAHA.118.011318
Chorin E, Hochstadt A, Granot Y, et al. Grapefruit juice prolongs the QT interval of healthy volunteers and patients with long QT syndrome. Heart Rhythm 2019; Published online: May 7, 2019
https://www.heartrhythmjournal.com/article/S1547-5271(19)30368-6/abstract
Tisdale JE, Jaynes HA, Kingery JR, et al. Development and validation of a risk score to predict QT interval prolongation in hospitalized patients. Circ Cardiovasc Qual Outcomes 2013 Jul; 6(4): 479-487
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3788679/
Tisdale JE, Jaynes HA, Kingery J, et al. Effectiveness of a Clinical Decision Support System for Reducing the Risk of QT Interval Prolongation in Hospitalized Patients. Circulation: Cardiovascular Quality and Outcomes 2014; 7(3): 381-390 Published online before print May 6, 2014
https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.113.000651
Haugaa KH, Bos JM, Tarrell RF, et al. Institution-Wide QT Alert System Identifies Patients With a High Risk of Mortality. Mayo Clin Proc 2013; 88(4): 315-325
https://www.mayoclinicproceedings.org/article/S0025-6196(13)00071-2/fulltext
BMJ Drug and Therapeutics Bulletin, Editorial Office. Drug and Therapeutics Bulletin. QT interval and drug therapy. BMJ 2016; 353: i2732
http://www.bmj.com/content/353/bmj.i2732
Li M, Ramos LG. Drug-Induced QT Prolongation And Torsades de Pointes
P&T Community 2017; 42(7): 473-477
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Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
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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