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April 7, 2020
From Preoperative Assessment to Preoperative Optimization
My, how things change! Years ago, prior to planned surgery patients got a gazillion blood tests, the results of which were often ignored. They often got cardiac stress tests, which then often led to a diagnostic cascade and possible cascade of interventions. They were also typically sent for “medical clearance” to a primary care physician, who often had little understanding of the nuances of perioperative medicine. That referral was mostly a “CYA” in case something went wrong during surgery.
Ten years ago, in our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” we advocated for a change away from the blood work and cardiac workup and toward a new focus on several key elements: risk factors for opioid-induced respiratory depression such as obstructive sleep apnea, risk factors for delirium, and the presence of frailty. Enough time needs to be allotted for addressing these risk factors plus attention to nutritional status and smoking cessation.
Later, we focused on programs to better prepare patients before surgery, particularly the elderly and frail. Some of our columns (listed below) have discussed ACS’s Strong for Surgery Program, the POSH (Perioperative Optimization of Senior Health) Program, the Hospital Elder Life Program (HELP), the Geriatric Surgery Verification Program, and several columns dealing with ”prehabilitation”.
This month’s issue of Anesthesia & Analgesia has several articles that call for a transition from preoperative assessment to preoperative optimization.
Aronson and colleagues (Aronson 2020a) detailed how they established a comprehensive preoperative assessment and management program to optimize patients for surgery at Duke University Hospital and School of Medicine.
They first describe what typically happens in the old preanesthesia clinic model, which is still commonly used for presurgical preparation. That usually includes an in-person clinic visit, a phone screen encounter, or a chart review only assessment. It typically covers a presurgery risk review, medication review, presurgical history, a limited physical examination plus things like signing the anesthesia consent, reviewing the advance directive, and dealing with financial matters. All too often the PAC visit occurs just before the scheduled surgical date, leaving little opportunity to effectively manage modifiable comorbid medical conditions. They note that the latter occur in up to 20% of patients scheduled for surgery, so an opportunity to positively impact surgical outcome and cost is lost.
They then go on to describe how their multidisciplinary group implemented a Preoperative Anesthesia and Surgical Screening (PASS) Clinic to screen patients and to more proactively and efficiently manage modifiable risks at the time a patient’s surgical candidacy is first considered. Preoperative screening and evaluation are protocol-driven and, if further optimization of a modifiable condition is warranted, referral is made to an optimization program. Because the surgical team is involved early, there is a better understanding of balancing mitigating modifiable risk factors versus the immediacy of the surgery.
A very important piece was their triaging system, used to determine which patients are phone screen eligible versus which need an in-person clinic visit. They used smart logic with an algorithm and decision rules to determine a patient’s status on key points (such as cardiac history, ability to lie flat, presence of pain) without the need for chart review. A calculated score determines eligibility for a phone screen or an in-person visit. They also created a list of the 100 highest-risk procedures to bypass phone screen consideration and be directly scheduled for an in-person visit.
They also developed tracking tools and scheduling tools to determine where a patient was in terms of readiness for surgery. And they had to develop a new system for determining acceptable timeframes in which elective surgery could be postponed while optimization took place. Anything <2 weeks was considered insufficient time to effectively initiate an optimization program.
A patient–nurse navigator assists patients with scheduling and coordination of care. A patient tracking dashboard was developed for the nurse navigator and other designated key stakeholders. A pamphlet called “the PASSport” was created and distributed to patients to help guide and communicate follow-up patient appointments.
The PASS Clinic was launched in September 2018. Specific optimization programs include a preoperative anemia clinic, preoperative diabetes clinic, preoperative penicillin allergy testing clinic, preoperative nutrition clinic, preoperative pain clinic, and preoperative smoking cessation clinic. An interface with the pre-existing Perioperative Optimization for Senior Health (POSH) clinic has been established for coordinated geriatric care. The article includes a comprehensive list of the items that are evaluated in the PASS clinic along with threshold criteria to trigger referral to those various optimization programs.
They also used smart technology to trigger best practice advisories (BPA’s) at specific times. For example, there might be one to ensure a diabetic patient had an endocrinology consults a specific day prior to surgery. Another triggered anesthesiology to follow a protocol for patients with obstructive sleep apnea.
The Duke program has not yet been in place long enough to report on how it impacted patient outcomes. An extensive list of outcome parameters (clinical, fiscal/economic, and functional) is being collected. But we have previously reported on some prehabilitation programs that did demonstrate a positive effect on outcomes.
In our April 10, 2018 Patient Safety Tip of the Week “Prepping the Geriatric Patient for Surgery” we discussed some other preoperative programs for frail elderly patients. The Perioperative Optimization of Senior Health (POSH) study (McDonald 2018) looked patients who were undergoing elective abdominal surgery and were considered at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, polypharmacy, visual or hearing loss, or simply deemed by their surgeons to be at higher risk). Intervention patients received a multidisciplinary comprehensive preoperative evaluation that focused on cognition, medications, comorbidities, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Despite higher mean age and morbidity burden, older adults who participated in this interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group. Though this was not a randomized, controlled trial (it was a before/after study design) and did not include a formal frailty measure, it is quite clear that most or all the intervention group patients were frail.
One small randomized trial of “prehabilitation” in high-risk patients (age >70 years and/or American Society of Anesthesiologists score III/IV) undergoing elective major abdominal surgery has recently been completed (Barberan-Garcia 2018).The researchers randomized 71 patients to the control arm and 73 to intervention. Prehabilitation covered 3 actions: motivational interview; high-intensity endurance training, and promotion of physical activity. The intervention group enhanced aerobic capacity, reduced the number of patients with postoperative complications by 51%, and the rate of complications.
Partridge et al. (Partridge 2017) conducted a randomized controlled study of preoperative comprehensive geriatric assessment and optimization vs. standard preoperative assessment in patients age 65 and above who underwent vascular surgery. They found preoperative comprehensive geriatric assessment was associated with a shorter length of hospital stay. Patients undergoing assessment and optimization had a lower incidence of complications and were less likely to be discharged to a higher level of dependency.
A randomized clinical trial in patients undergoing esophagogastric cancer surgery (Minnella 2018) found that prehabilitation improves perioperative functional capacity. The intervention consisted of preoperative exercise and nutrition optimization. Compared with the control group, the prehabilitation group had improved functional capacity (measured with absolute change in 6-minute walk distance) both before surgery and after surgery
In our January 15, 2019 Patient Safety Tip of the Week “Another Plus for Prehabilitation” we highlighted a study (Howard 2019) showing that “prehabilitation” does, indeed, have a positive impact on surgical outcomes. The Michigan Surgical and Health Optimization Program (MSHOP) is a formal prehabilitation program that engages patients in 4 activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. Patients were referred to the program at the discretion of their surgeon, with at least 2 weeks between referral and the surgery. The program focused on walking (patients receive a pedometer to track steps), breathing (patients receive an incentive spirometer), nutrition and stress management. They also received advice on smoking cessation, if appropriate. A DVD and brochure with instructions and resources for each domain was provided to patients, as well as a way to log their participation. During their involvement in the program, patients receive emails, phone messages, and text message-based reminders to
continue.
Overall, 70% of MSHOP patients complied with the program. MSHOP patients had better physiologic reserve (demonstrated by better systolic and diastolic blood pressures and lower heart rate compared to the other groups one hour into surgery). There was a significant reduction in class 3 to 4 complications in the MSHOP group (30%) compared with the nonprehabilitation (38%) and emergency (48%) groups. Total hospital charges averaged $75,494 for the MSHOP group, $97,440 for the nonprehabilitation group, and $166,085 for the emergency group. That translates to an average savings of $21,946 per patient. The authors note this represents a significant cost offset for a prehabilitation program. They conclude a prehabilitation program should be considered for all patients undergoing surgery.
More recent fiscal results of the MSHOP program were just reported (Mouch 2020). Compared to controls, those referred for prehabilitiation had significantly shorter median hospital length of stay (6 vs 7 days) and were more likely to be discharged to home (65.6% vs 57.0%). Moreover, there was considerable cost savings in the prehabilitation group ($31,641 vs $34,837 for total episode payments), with reduced costs for post-acute care for skilled nursing facility ($941 vs $1,566) and home health ($829 vs $960) services. Because their study was based upon claims data, they were unable to relate the LOS or cost savings to the occurrence of surgical complications.
A recent review of prehabilitation in gynecological surgery (Miralpeix 2019) recommended a safe, reproducible, functional, and easy-to-apply multimodal prehabilitation program for gynecologic oncology practice based on patient-tailored pre-operative medical optimization, physical training, nutritional counseling, and psychological support.
Not all studies have shown that prehabilitation improves outcomes. One recent randomized controlled study (Carli 2020) found that, in frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. A systematic review (McIsaac 2017) found that few interventions have been tested to improve the outcomes of frail surgical patients, and most available studies are at substantial risk of bias. McIsaac is a lead researcher of an ongoing large randomized PREHAB clinical trial (McIsaac 2018). This is a single-center, parallel-arm randomized controlled trial of home-based exercise prehabilitation versus standard care among consenting patients >60 years having elective cancer surgery (intra-abdominal and intrathoracic) and who are frail (Clinical Frailty Scale >4). The intervention consists of > 3 weeks of exercise prehabilitation (strength, aerobic and stretching). The primary outcome is the 6 min walk test at the first postoperative clinic visit. Secondary outcomes include the short physical performance battery, health-related quality of life, disability-free survival, complications and health resource utilization. Hopefully the ongoing McIsaac study will provide definitive answers about utility of prehabilitation in preparing the frail geriatric patient for surgery.
In addition to the Duke study, the Mayo Clinic Proceedings have recently had a series of articles on preoperative and perioperative medicine. The editorial introducing these (Mauck 2020) discusses how modern perioperative medicine has evolved into a true multidisciplinary specialty that extends beyond the surgical and hospital encounter and includes preoperative risk evaluation and optimization as well as postoperative post-hospitalization recovery. While it does discuss the benefits of ERAS (Enhanced Recovery After Surgery) programs (see our February 11, 2020 Patient Safety Tip of the Week “ERAS Rocks!”), it strongly endorses the need for more during the preoperative phase. It notes that prehabilitation strategies focus on proactively starting the rehabilitation process in the weeks before surgery and include structured exercise programs to optimize cardiovascular, respiratory, and muscular conditioning, in addition to optimizing modifiable risk factors like malnutrition, anemia, and psychosocial issues. Because many patients are older and have multiple comorbidities, there is a need for non-anesthesiologist, non-surgeon clinicians who specialize in this area to provide the care needed.
The article on preoperative evaluation before noncardiac surgery (Bierle 2020) notes that preoperative risk assessment and risk modification requires analysis of:
It goes into detail about assessing the risks for cardiac and pulmonary complications, DVT risk, bleeding risk, delirium risk, obstructive sleep apnea, post-op nausea and vomiting (PONV), and others. It does cover preoperative testing but stresses any testing must be done in a cost-effective manner that takes into account both the risks of the surgery (noting that some surgeries require little or no testing) and patient-specific risks. It specifically notes the importance in the elderly of cognitive screening and assessment for delirium risk and fall risk, noting that addressing malnutrition and frailty preoperatively with a program of “prehabilitation” improves postoperative outcomes.
The Duke PASS program comes at a time when there is increased scrutiny on how patients are managed before and during surgery. The Doctors Company recently released its Anesthesia Closed Claims Study (Ranum 2020), which found an increase in the percentage of claims related to improper management, noting that limited opportunities to conduct preoperative assessments were a significant contributing factor. They specifically note “Older and sicker patients needed closer investigation but production pressures often limited testing and input from attending or referral physicians.” They also note that those pressures limit their ability to “recommend safer locations for anesthesia care (e.g., hospital operating room vs. ambulatory surgery or GI or cardiac labs) or to prepare for complications that might occur as a result of multiple comorbidities or complicated health histories.” The importance of comorbidities was highlighted by the fact that, in cases with inadequate history and physical as a contributing factor, obesity impacted patients’ care in almost three times as many cases as other anesthesia cases, obstructive sleep apnea was six times more likely, hypertension three times more likely, and other comorbidities twice as frequently. Among their recommendations were ensuring that anesthesiology staff have adequate time and opportunity to conduct preop assessments and opportunities to refer patients to specialists to evaluate comorbidities. Sounds exactly what the Duke PASS program does!
Aronson and colleagues, in a separate editorial (Aronson 2020b), issue a call to action for preoperative optimization and discuss the many systemic, institutional, individual, and economic barriers and conflicts of interest that have prevented the transformation in the past.
It’s pretty clear to us that we need to resist the desires of both patients and surgeons to expedite elective surgery and, instead, allow adequate time for both preop assessment and patient optimization prior to surgery. Duke has done an outstanding job of designing and implementing a system that allows adequate time and funnels patients in a protocol-driven manner to get the care needed to make them better candidates for their planned surgery.
Some of our columns on preparation of patients prior to surgery:
Some of our prior columns on preoperative assessment and frailty:
References:
Aronson S, Murray S, Martin G, et al. Roadmap for transforming preoperative assessment to preoperative optimization. Anesth Analg 2020; 130: 811-819
McDonald SR, Heflin MT, Whitson HE, et al. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older AdultsThe Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg 2018; 153(5): 454-462
Barberan-Garcia A, Ubré M, Roca J, et al. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. Ann Surg 2018; 267(1): 50-56
https://insights.ovid.com/pubmed?pmid=28489682
Partridge JS, Harari D, Martin FC, et al. Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. Br J Surg 2017; 104(6): 679-687
https://bjssjournals.onlinelibrary.wiley.com/doi/abs/10.1002/bjs.10459
Howard R, Yin YS, McCandless L, et al. Taking Control of Your Surgery: Impact of a Prehabilitation Program on Major Abdominal Surgery. J Amer Coll Surg 2019; 228(1): 72-80 Published online: October 22, 2018
https://www.journalacs.org/article/S1072-7515(18)32073-8/fulltext
Mouch CA, Kenney BC, Lorch S, et al. Statewide Prehabilitation Program and Episode Payment in Medicare Beneficiaries. Journal of the American College of Surgeons 2020; 230(3): 306-313.e6
https://www.journalacs.org/article/S1072-7515(19)32217-3/fulltext
Miralpeix E, Mancebo G, Gayete S, et al.. Role and impact of multimodal prehabilitation for gynecologic oncology patients in an enhanced recovery after surgery (ERAS) program. Int J Gynecol Cancer 2019; 29:1235-1243
McIsaac DI, Jen T, Mookerji N, et al. Interventions to improve the outcomes of frail people having surgery: A systematic review. PLOS One 2017; Published: December 29, 2017
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0190071
McIsaac DI, Saunders C, Hladkowicz E, et al. PREHAB study: a protocol for a prospective randomised clinical trial of exercise therapy for people living with frailty having cancer surgery. BMJ Open. 2018; 8(6): e022057. Published online 2018 Jun 22
https://bmjopen.bmj.com/content/8/6/e022057
Mauck KF. Introduction to Thematic Reviews on Perioperative Medicine. Mayo Clinic Proceedings 2020; 95(4): 642-643
Bierle DM, Raslau D, Regan DW, et al. Preoperative Evaluation Before Noncardiac Surgery. Mayo Clinic Proceedings 2020; 95(4): 807-822
https://www.mayoclinicproceedings.org/article/S0025-6196(19)30413-6/fulltext
Ranum D. Anesthesiology Closed Claims Study. The Doctors Company 2020; February 2020
https://www.thedoctors.com/articles/anesthesiology-closed-claims-study/
Aronson S, Martin G, Gulur P, et al. Preoperative optimization: a continued call to action. 7, 2020Anesth Analg 2020; 130: 808-810
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April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
So far, we have refrained from discussing the COVID-19 pandemic, largely because all of you have been deluged by articles about it. But there have been a few good recommendations recently that pertain specifically to patient safety issues that we feel merit your attention. We probably should not call these “tidbits” because they actually represent extremely serious issues in patient (and staff) safety.
Antimalarial drugs
The first time we heard President Trump hyping chloroquine or hydroxychloroquine plus azithromycin for COVID-19, our patient safety antenna popped up. Those drugs are on our list of drugs that can prolong the QT interval and predispose to Torsade de Pointes (see our columns on Torsade listed below). We immediately sent a warning to residents of our local community, advising those who were considering use of these drugs to make sure their physician was aware of the danger and planned EKG monitoring if those drugs were to be used. We have no comment on the efficacy of these antimalarials in COVID-19 but they are being widely used. Hence, it is critical that the risk for Torsade be considered.
The Presidents of the American Heart Association, American College of Cardiology, and Heart Rhythm Society have issued recommendations on using hydroxychloroquine and azithromycin to treat COVID-19 in patients (Roden 2020). They recommend the following mechanisms to minimize arrhythmia:
Electrocardiographic/QT interval monitoring:
Correction of hypokalemia to levels of >4mEq/Land hypomagnesemia to levels of >2 mg/dL.
Avoid other QTc prolonging agents whenever feasible.
Mayo Clinic cardiologist Michael Ackerman was quite vocal in an interview with NBC News (Przybyla 2020) about laymen and physicians talking about use of these antimalarial drugs without discussing the potential serious cardiac rhythm implications. Ackerman and his Mayo Clinic colleagues have created a nice algorithm, published in Mayo Clinic Proceedings (Giudicessi 2020), to help physicians more safely prescribe hydroxychloroquine by identifying patients at greatest risk for drug-induced sudden cardiac death.
ISMP (Institute for Safe Medication Practices) also warned about the potential arrhythmogenic effects of these drugs (ISMP 2020a). They note that ventricular arrhythmias and torsade de pointes have been reported, and drug labeling warns against administering these drugs with other drugs that have the potential to prolong the QT interval. They note that azithromycin itself may prolong the QT interval, so taking the drug in combination with hydroxychloroquine or chloroquine may enhance the overall QTc-prolonging effect. Patients with additional risk factors for QTc prolongation may be at even higher risk. Thus, patients taking this combination should be monitored for QTc interval prolongation and ventricular arrhythmias.
Combinations of drugs that can prolong the QT interval might be expected to be particularly dangerous. Hence, the extreme concern about adding azithromycin to one of the antimalarial agents. Patients with COVID-19 and other multiple comorbidities are likely to be on other medications that may prolong the QT interval. Also, since COVID-19 may also present with gastrointestinal symptoms, some patients may have been taking the commonly used anti-diarrheal loperamide (Imodium and numerous OTC formulations) that the FDA warned about in 2016 (FDA 2016).
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.
The only study we know of where the effects of this hydroxychloroquine/azithromycin combination on the QT interval has not been peer reviewed but showed the QTc was prolonged maximally from baseline between days 3 and 4 (Chorin 2020). In 30% of patients the QTc increased by greater than 40msec and in 11% of patients the QTc increased to >500 msec (considered the dangerous level in most).
Furthermore, the additive effect of drugs on the QT interval may not just apply when the drugs are given concomitantly. ISMP (ISMP 2020b) described a patient who suffered cardiac arrest while on hydroxychloroquine after azithromycin had been discontinued. The hydroxychloroquine was started one day after azithromycin had been discontinued. On day 5 the patient developed ventricular fibrillation and cardiac arrest and subsequent EKG showed a QTc of 605 msec (a QTc above 470 msec is considered abnormally long in women). The article goes on to describe the long half lives of each of these drugs (hydroxychloroquine 40 days, chloroquine 5 days, azithromycin 72 hours).
If use of any of these drugs is considered, the patient should have both a baseline EKG to measure the QTc interval and regular EKG’s to monitor for prolongation. For those patients who are hospitalized, many physiological monitoring systems have the capability of monitoring the QT interval and can provide alerts. In those patients not on continuous monitoring (or where the monitors cannot determine QT intervals) daily 12-lead EKG’s should be done.
Congenital and drug-induced QT prolongation are not the only factors putting these patients at risk for malignant arrhythmia. Hospitalized patients have a whole host of other factors that may prolong the QT interval and precipitate malignant arrhythmias in vulnerable patients. These include underlying heart disease, electrolyte abnormalities (eg. hypokalemia, hypomagnesemia, hypocalcemia), COPD, renal or hepatic impairment, and bradycardia) all of which may be precipitating factors. Many seriously ill patient hospitalized with COVID-19 may also share some of these conditions.
For those of you who are interested, there is a YouTube video about multiple other aspects of chloroquine and hydroxychloroquine from the University of Washington Medicine (Escobar 2020).
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”
June 25, 2019 “Found Dead in a Bed – Part 2”
Fire risk in an oxygen-rich environment
The UK National Health Services issued an alert warning of the risk of fire in the COVID-19 hospital environment (NHS 2020). The density of ventilators on COVID-19 units may lead to an oxygen-rich environment that can predispose to fires. In such and oxygen-rich environment, any spark or heat source (for example, from a defibrillator) could trigger a fire. One might anticipate that splitting ventilators (i.e. using one ventilator for two patients) might make oxygen leaks easier and increase the oxygen in the air. Even in non-ICU settings, the increased use of oxygen could be problematic. The NHS alert stresses facilities need to ensure there is good natural and mechanical ventilation in all areas where oxygen is being used.
Thrombotic tendencies
COVID-19 has increasingly been associated with thrombotic events (large vessel clots, DVT/PE, arterial events, small vessel disease, and microvascular thrombosis (Phend 2020). The International Society on Thrombosis and Haemostasis (ISTH) has published guidelines regarding anticoagulants in COVID-19 patients (Moll 2020). An article on coagulopathy in COVID-19 (Shaw 2020) discusses multiple opinions on the issues of prophylactic anticoagulants versus full anticoagulation.
A recent correspondence in the New England Journal of Medicine (Zhang 2020) described an older man in China with a history of hypertension, diabetes, and stroke who developed COVID-19 and required mechanical ventilation. He had evidence of ischemia in 3 limbs and CT scan of the brain showed bilateral cerebral infarcts in multiple vascular territories. Lab findings included leukocytosis, thrombocytopenia, an elevated prothrombin time and partial thromboplastin time, elevated levels of fibrinogen and d-dimer, and antiphospholipid antibodies. Two other patients in the ICU had similar findings. They note that the presence of these antibodies may rarely lead to thrombotic events that are difficult to differentiate from other causes of multifocal thrombosis in critically patients, such as disseminated intravascular coagulation, heparin-induced thrombocytopenia, and thrombotic microangiopathy.
A cohort study from Wuhan, China found that D-dimer levels over 1 mcg/L at admission predicted an 18-fold increase in the odds of death before discharge, though the exact mechanism for this is unclear (Zhou 2020).
Independent double checks
We’ve discussed the pros and cons of double checks in numerous columns, Truly independent double checks do have a role in certain scenarios. But requiring a double check may increase the exposure of a healthcare professional to COVID-19. ISMP (ISMP 2020c) recently addressed the need to balance the benefits of double checks versus the risks of exposure and the need to conserve personal protective equipment (PPE) when doing double checks in the COVID-19 environment. They found that most organizations are establishing ways to conduct critical parts of independent double checks without entering a patient’s room. For example, a hard stop in EHR’s requiring
dual documentation of verification before proceeding now reflects only those components of the check that can be accomplished outside the patient’s room.
They also describe how some hospitals became innovative. Where infusion pumps remain in the patient’s room, the nurse who enters the room takes a picture of the pump screen using a mobile phone device left in the room, and sends the picture to a nurse outside the room via a secure messaging system. This allows most components of the independent double check to occur. (We’ll have to add that to our list of pros and cons of smartphones in healthcare!).
Medication reconciliation and discharge communication
ISMP Canada (ISMP Canada 2020) received a report about a student health care provider who obtained a best possible medication history (BPMH) from a patient in a face-to-face interview. It was later discovered that the patient was under investigation for suspected COVID-19 virus. A review of the circumstances of this incident brought to light an opportunity for improvement. The facility consequently planned to implement a process to conduct medication history interviews by phone.
That means you need to evaluate (both on the hospital side and the patient side) the availability for telephone, video-calling, and email communication, including security and practicality of internet access, email accounts, in-room telephone, mobile phone, internet-based video-calling platform, intercom, or 2-way communicating baby monitors. Staff in your registration department will need to document the patient’s mobile phone number and email address to facilitate virtual conversations and reduce the need for in-room meetings.
They go on to describe the process of medication reconciliation, including not only digital identification of medications but also visual identification (via video or sending photographs of the pills or containers via email).
They go on to describe how the same systems can be used to educate patients at or just after hospital discharge (including ways to involve the patient’s PCP and community pharmacy).
Wow! They did this because of the COVID-19 pandemic, but think how this could be used at any time. Particularly now that CMS is relaxing its guidelines on telemedicine, what better way to conduct the annual “wellness visit” than by using telemedicine. The patient doesn’t have to bring in their “brown bag” of medications but can simply show everything in their medicine cabinet to you via these communication links. It saves all time and still allows for face-to-face interaction.
Prehabilitation for COVID-19
Last week’s Patient Safety Tip of the Week “From Preoperative Assessment to Preoperative Optimization” discussed how prehabilitation may help reduce complications prior to surgery. An opinion piece (Silver 2020) in the most recent issue of the British Medical Journal suggests we should use prehabilitation to prepare patients for COVID-19 infections. Julie Silver, Chair of Harvard’s Department of Physical Medicine, notes that strategies we’ve employed to slow the spread of COVID-19 (eg. social distancing, sheltering in place) could have the unintentional effect of decreasing physical activity and contributing to cardiopulmonary deconditioning. That would be particularly devastating in the elderly, who are already at risk of increased morbidity and mortality if they get COVID-19. She goes on to posit that there currently exists a window of opportunity whereby physicians can recommend a best practice approach and advise patients and the public about how to maintain and optimize their baseline fitness and nutritional health, using techniques used prior to surgery, such as a combination of exercise, nutrition, smoking cessation, and stress reduction. She emphasizes that small changes in cardiopulmonary fitness may have a large impact on patients who are frail, including elderly patients with multiple comorbidities. All these interventions can be delivered while patients are practicing social distancing or are sheltering in place and can be easily delivered via telemedicine. These are great recommendations. Don’t just think about managing patients once they contract or have been exposed to coronavirus. Identify your highest risk patients (the elderly, those with multiple comorbidities, and the frail) and interact with them via telemedicine to get them involved in prehabilitation to improve the chances of survival if and when they do develop COVID-19.
References:
Roden DM, Harrington RA, Poppas A, Russo AM. Considerations for Drug Interactions on QTc in Exploratory COVID-19 (Coronavirus Disease 2019) Treatment. Circulation 2020; Published ahead of print April 8, 2020
https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047521
Przybyla H. Mayo Clinic cardiologist: 'Inexcusable' to ignore hydroxychloroquine side effects. NBC News 2020; April 7, 2020
Giudicessi JR , Noseworthy PA, Friedman PA, Ackerman MJ. Urgent guidance for navigating and circumventing the QTc prolonging and torsadogenic potential of possible pharmacotherapies for COVID-19. Mayo Clin Proc 2020; 95(x): xx-x [published online ahead of print March 25, 2020]
https://mayoclinicproceedings.org/pb/assets/raw/Health%20Advance/journals/jmcp/jmcp_covid19.pdf
ISMP (Institute for Safe Medication Practices). Limit use and protect supplies of unproven but widely prescribed COVID-19 treatment. ISMP Medication Safety Alert! Acute Care Edition 2020; Special Edition 25(6): 1, 3-5 March 26, 2020
https://www.ismp.org/acute-care/medication-safety-alert-march-26-2020
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
CredibleMeds® website
Chorin E, Dai M, Shulman E, et al. The QT Interval in Patients with SARS-CoV-2 Infection Treated with Hydroxychloroquine/Azithromycin. medRxiv 2020; 2020.04.02.20047050; Preprinted without peer review April 3, 2020
https://www.medrxiv.org/content/10.1101/2020.04.02.20047050v1
ISMP (Institute for Safe Medication Practices). Patient taking hydroxychloroquine right after discontinuing azithromycin develops QTc prolongation and cardiac arrest. ISMP Medication Safety Alert! Acute Care Edition 2020; Special Edition 25(7): 1, 3-4 April 9, 2020
https://www.ismp.org/acute-care/special-edition-medication-safety-alert-april-9-2020
Escobar ZK. Chloroquine & Hydroxychloroquine. University of Washington Medicine. YouTube March 19, 2020
https://www.youtube.com/watch?v=an4WZv_spT4&list=PL9P1nWBXsofsRyl96njQIQUFTEoeg7aXU&index=4&t=0s
NHS (National Health Services UK). Novel coronavirus (COVID-19) standard operating procedure. Design note: COVID-19 ward for intubated patients. NHS 2020; March 22, 2020
Phend C. Anticoagulation Guidance Emerging for Severe COVID-19
— Pragmatic choices dominate as guidelines are shaping up. MedPage Today 2020; April 8, 2020
https://www.medpagetoday.com/infectiousdisease/covid19/85865
Moll S. COVID-19 and Coagulopathy – Two Management Guidance Documents For Health Care Professionals. Clot Connect 2020; Posted on March 26, 2020
Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. NEJM 2020; April 8, 2020
https://www.nejm.org/doi/full/10.1056/NEJMc2007575
Shaw G. Abnormal Clotting and COVID-19. Infectious Disease Special Edition 2020; April 9, 2020
Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet 2020; 395(10229): 1054-1062
https://www.sciencedirect.com/science/article/pii/S0140673620305663
ISMP (Institute for Safe Medication Practices). Suspending independent double checks. ISMP Medication Safety Alert! Acute Care Edition 2020; Special Edition 25(7): 1-2 April 9, 2020
https://www.ismp.org/acute-care/special-edition-medication-safety-alert-april-9-2020
ISMP Canada. Virtual Medication History Interviews and Discharge Education. ISMP Canada Safety Bulletin 2020; 20(2): April 7, 2020
Silver JK. Prehabilitation could save lives in a pandemic BMJ 2020; 369 :m1386
https://www.bmj.com/content/369/bmj.m1386
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April 21, 2020
Parenteral Nutrition Safety Issues
Parenteral nutrition (PN), often called total parenteral nutrition or TPN, is a valuable therapy we use in most hospital settings and other medical venues. But it has largely escaped our attention from a patient safety perspective. That’s surprising since PN issues played a significant contributory role in the Josey King tragedy (Niedowski 2003) that was a seminal event in the patient safety movement. And we’ve often seen complications related to the catheters and lines used to administer PN.
A great review of parenteral nutrition safety issues was just recently published (Mirtallo 2020) and it sure opened our eyes! Pharmacists Jay Mirtallo and Phil Ayers begin by acknowledging that adverse events (AEs) related to PN are rarely reported but are likely to be associated with harm when they do occur.
They go on to describe the components of the PN system: assessment by dietician or nutrition support service, determination of indication for PN, order, review and verification of order, compounding and preparation of the PN, dispensing (which includes labeling and delivery), administration by a nurse or caregiver (includes patient ID verification and ensuring appropriate access, infusion rate, pump function, and infection control measures), monitoring (the venous access device, metabolic response, disease outcomes), and again restarting the cycle with assessment. Similar to the medication use process, each of these steps presents an opportunity for error, so it’s surprising we don’t hear about more errors in the PN process. Each step also requires documentation, which also gives rise to opportunities for error if that documentation is not accessible (or simply ignored) by all parties on the overall process or if the terminology between systems is not compatible.
The authors cite statistics from studies they had previously been a part of. One study (Sacks 2009) had found an overall incidence of medication errors to be 15.6 errors/1000 parenteral nutrition prescriptions compounded. Of those errors, 1% occurred during the prescription process (and was detected before preparation), 39% occurred during the transcription process, 24% during preparation, and 35% during the administration process. Most errors (91%) were considered nonharmful, but 8% contributed to or resulted in temporary harm to a patient.
The second study (Seres 2006) reported on a survey by the American Society for Parenteral and Enteral Nutrition (ASPEN). Almost two-thirds of the survey respondents reported observing 1 to 5 PN-related errors per month. 71% of errors were related to PN electrolytes. Respondents estimated that 35% of the errors required increased monitoring, 25% resulted in harm, 3.3% were almost fatal, and 1.5% were fatal.
Another review (Mirtallo 2004) found the following serious outcomes resulting from PN errors:
Also, product shortages over the years have sometimes resulted in micronutrient deficiencies of copper, selenium, and thiamine.
ISMP’s Michael Cohen, writing in JPEN (Cohen 2012), noted the following issues in parenteral nutrition:
Another review on PN errors reported in ISMP’s MEDMARX system (Storey 2016) found many errors related to omission of ingredients. Fat emulsions and electrolytes were the PN ingredients most frequently associated with error. Insulin was the ingredient most often associated with patient harm. While omission occurred in all modes, it was most common in ordering and transcribing.
Earlier this month, in our What's New in the Patient Safety World column “More Gems from ISMP”, we noted 2 recent ISMP articles, both of which mentioned issues related to parenteral nutrition. ISMP’s Targeted Medication Safety Best Practices for Hospitals (ISMP 2020a) had as its Best Practice #11 “When compounding sterile preparations, perform an independent verification to ensure that the proper ingredients (medications and diluents) are added, including confirmation of the proper amount (volume) of each ingredient prior to its addition to the final container.” Wording in the previous version had focused on high-alert medications and had specifically included parenteral nutrition as being one of the preparations requiring independent verification.
Then, in its Top 10 Medication Errors and Hazards (ISMP 2020b), number 10 was that 1,000-fold overdoses with zinc can occur with parenteral nutrition, particularly in children. They cite a case in 2019 involving a child for whom 700 mg instead of 700 mcg of zinc was prescribed when the pediatric PN template defaulted to mg dosing units. They note that this order could not have been changed to mcg had the physician even noticed the error, and that a dose warning was not issued during the prescribing process. (ISMP had reported a very similar case of zinc overdose due to using mg rather than mcg in its September 6, 2007 Safety Alert). ISMP advises all healthcare providers to build, test, and heed maximum dose warnings in PN order entry systems. That should include a hard stop for critical zinc overdoses (e.g., above 250 mcg/kg for pediatric PN). Pediatric PN templates should default to mcg dosing units for zinc, which should also correspond to the way orders are entered in automated compounders. ISMP also encourages drug information database vendors to create needed critical dose warnings for IV zinc and other trace elements, if they do not currently exist.
That’s not the first time ISMP has noted problems related to disparity between units used in order entry systems versus those used in pharmacy compounding systems. In 2012 ISMP reported on a case in which orders per kg were confused with orders per day, resulting in a patient receiving a very hypotonic solution due to an unusually large amount of sterile water in the preparation (ISMP 2012). ISMP again focused on the need to standardize and match dosing units in the prescribing and pharmacy systems. It also emphasized the importance of issuing warnings, using redundancies and independent double checks in steps for verification, and providing clear labelling.
ISMP’s recommendations were echoed in a call to action co-published by the American Society of Health‐System Pharmacists (ASHP), the Academy of Nutrition and Dietetics (AND), and the American Society for Parenteral and Enteral Nutrition (ASPEN) (Vanek 2018). Key areas identified by the work group for this publication were:
Catching errors before they cause harm in patients is critical. In our March 13, 2018 Patient Safety Tip of the Week “Intercepting Errors” we noted a study that developed an automated medication administration error detection system that focused on reconciling 10 high-risk continuous intravenous infusions and medications prescribed to NICU inpatients (Ni 2018). Among the targeted medications/infusions, TPN had the second highest medication administration error rate. The automated detection system has the potential to reduce harm exposure significantly for all medications via real-time messaging technology. The study showed the most substantial reductions were realized for long-time intravenous medications/infusions such as TPN and lipid.
The current review by Mirtallo and Ayers (Mirtallo 2020) also notes that recent introduction of some new lipid injectable emulsions (ILE’s) require development of new policies and procedures that take into account special filtering and infusion requirements.
Discussion about CLABSI’s (central line-associated bloodstream infections) is beyond the scope of today’s column, but just be reminded that PN is a frequent reason for use of central lines or PICC lines. Also, in our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” we noted that TPN was one of several significant risk factors for upper extremity venous thrombosis associated with PICC insertion (Marnejon 2012).
We have one other consideration of our own: what happens when PN infusion is interrupted, either intentionally or unintentionally, particularly when PN is being coordinated with insulin administration? For example, suppose the line for infusing PN becomes inoperable (eg. thrombosis) and the patient is receiving a long-acting insulin. You need to have a protocol in place that would alert you to the danger of hypoglycemia in this instance. That could especially be a problem in patients receiving PN at home. On the other hand, suppose you withhold insulin when you send a patient for a procedure in radiology or elsewhere. You have to remember that the patient might be vulnerable to hyperglycemia if the PN continues while the insulin was withheld.
This excellent review by Mirtallo and Ayers (Mirtallo 2020) really opened our eyes to a topic we’ve largely neglected. We’ll bet that many of you do not even include data on PN errors in your Pharmacy & Therapeutics review programs. We suspect your organizations can also benefit from the many lessons and recommendations in the review.
References:
Niedowski E. Medical error kills Hopkins cancer patient. The Baltimore Sun (2003); December 19, 2003
https://www.baltimoresun.com/news/bs-xpm-2003-12-19-0312190182-story.html
Mirtallo JM, Ayers P. Parenteral Nutrition Safety. Pharmacy Practice News 2020; April 15, 2020
https://www.pharmacypracticenews.com/Review-Articles/Article/04-20/Parenteral-Nutrition-Safety/57830
Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication errors related to the parenteral nutrition pro-cess in a large university teaching hospital. Pharmacotherapy 2009; 29(8): 966-974
https://accpjournals.onlinelibrary.wiley.com/doi/10.1592/phco.29.8.966
Seres D, Sacks GS, Pedersen CA, et al. Parenteral nutrition safe practices: results of the 2003 American Society for Parenteral and Enteral Nutrition Survey. JPEN J Parenter Enteral Nutr 2006; 30(3): 259-265
https://onlinelibrary.wiley.com/doi/abs/10.1177/0148607106030003259
Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenteral nutrition. JPEN J Parenter Enteral Nutr 2004; 28: s39-s70
https://onlinelibrary.wiley.com/doi/abs/10.1177/0148607104028006S39
Cohen MR. Safe practices for compounding of parenteral nutrition. JPEN J Parenter Enteral Nutr. 2012; 36(suppl): 14s-19s
https://onlinelibrary.wiley.com/doi/abs/10.1177/0148607111435332
Storey MA, Weber RJ, Besco K, et al. Evaluation of parenteral nutrition errors in an era of drug shortages. Nutr Clin Pract 2016; 31(2): 211-217
https://onlinelibrary.wiley.com/doi/abs/10.1177/0884533615608820
ISMP (Institute for Safe Medication Practies). Targeted Medication Safety Best Practices for Hospitals. ISMP 2020; February 21, 2020
https://www.ismp.org/guidelines/best-practices-hospitals
ISMP (Institute for Safe Medication Practices). Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards. ISMP 2020; January 16, 2020
ISMP (Institute for Safe Medication Practices). Mismatched Prescribing and Pharmacy Templates for Parenteral Nutrition (PN) Lead to Data Entry Errors. ISMP 2012; June 28, 2012
Vanek VW, Ayers P, Kraft M et al. A call to action for optimizing the electronic health record in the parenteral nutrition workflow. Nutr Clin Pract 2018; 33: e1-e21
https://onlinelibrary.wiley.com/doi/full/10.1002/ncp.10095
Ni Y, Lingren T, Hall ES, et al. Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit. Journal of the American Medical Informatics Association 2018; 25(5): 555-563 Published: 10 January 2018
https://academic.oup.com/jamia/article/25/5/555/4797402
Marnejon T, Angelo D, Abu Abdou A, Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters. J Vasc Access 2012; 13(2): 231-238
https://journals.sagepub.com/doi/pdf/10.5301/jva.5000039
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April 28, 2020
Can the Lab Spot Frailty?
Recognizing frailty is important for predicting complications in patients hospitalized for either medical or surgical reasons. Such recognition may help prevent complications and help plan for post-hospital care. It may also identify patients for whom “prehabilitation” may be useful. Our many columns on the impact of frailty on patient outcomes have highlighted a variety of useful tools to identify frail patients. But can the lab be used to identify frail patients? A new study suggests that it can, indeed.
Ellis and colleagues (Ellis 2020) created a frailty index (called “FI-Laboratory”) from routine admission laboratory investigations in a prospective cohort of older adults admitted to a large tertiary hospital in the United Kingdom.
The authors propose that the FI-Laboratory “may be a plausible ‘front door’ tool that could inform potential interventions that may include management escalation, specific treatment paths, implementation of comprehensive geriatric assessments, and admission to ‘senior-friendly’ units.”
In the current study of consecutive patients admitted to an acute geriatric unit, the researchers used 2 summary measures quantifying chronic and acute health states: the Clinical Frailty Scale (CFS) score (also known as the Rockwood score that we have discussed in several prior columns), and the laboratory frailty index (FI-Laboratory). Data for FI-Laboratory items came from common laboratory tests that are routinely undertaken for clinical investigations within the first 72 hours of admission. There are 27 lab tests (listed in their supplemental table) from which the calculate the FI-Laboratory score. Their analysis included data from 2552 separate admissions for 1750 patients.
Higher CFS and FI-Laboratory scores were both associated with more days in hospital during the study period, even after accounting for multiple clinical and demographic factors. An increase in the CFS was associated with an increase in admission days (rate ratio 1.43). Each 0.10 (3 deficits) increase in the FI-Laboratory was associated with an increase in admission days (RR 1.47).
Similarly, higher CFS and FI-Laboratory were associated with being discharged to a higher level of care (odds ratio 1.30 for a 1-point increase in the CFS and 1.39 for a 0.10 increase in the FI-Laboratory). A presentation of falls or delirium was also associated with being discharged to a higher level of care.
Readmissions also correlated with CFS and FI-Laboratory scores. Hazard ratios for readmission were 1.18 for a 0.10 increase in the FI-Laboratory score and 1.26 for an additional point on the CFS. Older age was also an independent predictor of readmissions.
Lastly, both scores were predictors of mortality. 56.4% of the participants died during the follow-up period. A single point higher CFS and a 0.10 increase in the FI-Laboratory score were associated with increased risk of death (respective hazard ratios for mortality were 1.39 and 1.45).
The authors conclude that the FI-Laboratory score offers distinct, yet complementary, information to the chronic accumulation of deficits and is associated with several adverse outcomes, in addition to those conferred by the CFS and to chronological age. They suggest that the FI-Laboratory score can usefully measure accumulated deficits in older adults who present to the hospital with acute illness. The FI-Laboratory score combines features that both predispose to and precipitate acute illness. They posit that, by quantifying both acute and chronic deficits, the score may draw attention to risk that is not apparent clinically.
We generally favor frailty instruments that are simple and easy to administer, such as the Fried Index or the Modified Frailty Index (see our May 31, 2016 “More Frailty Measures That Predict Surgical Outcomes”). Even simpler measures, such as gait speed or the timed up-and-go test, may be very useful in predicting frailty and complications in various settings. But we can see a real value in the FI-Laboratory score. It can be calculated easily from readily available laboratory data. It could identify patients at risk for these adverse outcomes in whom there was no pre-existing data to determine a CFS score or other measure of frailty.
This study was done a a single center. It would be useful to see if the findings can be validated at other medical centers. But we definitely see promise for use of the FI-Laboratory score.
Some of our prior columns on preoperative assessment and frailty:
References:
Ellis HL, Wan B, Yeung M, et al. Complementing chronic frailty assessment at hospital admission with an electronic frailty index (FI-Laboratory) comprising routine blood test results. CMAJ 2020; 192(1): E3-E8
https://www.cmaj.ca/content/192/1/E3
Supplemental tables
https://www.cmaj.ca/content/cmaj/suppl/2019/12/27/192.1.E3.DC1/190952-res-1-at.pdf
Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173: 489-495
https://www.cmaj.ca/content/173/5/489
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May 5, 2020
COVID-19 and the Dental Office
We’ve done several columns on patient safety in dental practice. But COVID-19 certainly raises a new concern. Most dental practices had closed (except for emergencies) during the current COVID-19 pandemic. But many are now preparing to re-open as some of the state-imposed restrictions are being relaxed. You should be concerned not only if you are a dentist or work in a dental office, but also if you are a patient needing dental care or services.
The basic concern is that the nature of dental instruments, particularly high speed drills, makes aerosolization unavoidable. So it is incumbent upon all dental practices to ensure that their staffs and their patients are protected against exposure to coronavirus.
A lot of planning needs to take place prior to re-opening a dental practice. Considerations include: patient and staff screening procedures, infection control procedures, maintaining social distancing, scheduling, staff education and training, patient education, alternate workflows, inventory of PPE, contingency planning, and others.
We’d start with an inventory of PPE (personal protective equipment). Your inventory of PPE should also take into account your likely “burn” rate (i.e. how fast you will go through your PPE supplies). If hospitals are any indicator of “burn” rates, make sure your estimates of PPE needs are adequate. Important: If your dental office is unable to secure the appropriate PPE to safely operate, your practice should not reopen until it is obtained.
Of course, PPE (personal protective equipment) is of greatest concern. CDC guidelines (CDC 2020a) recommend, during aerosol-generating procedures (e.g. use of dental handpieces, air/water syringe, ultrasonic scalers), put on one of the following:
an N95 respirator or a respirator that offers a higher level of protection such as other disposable filtering facepiece respirators, powered air-purifying respirators (PAPR’s), or elastomeric respirators. CDC has a good section on PPE (personal protective equipment), including sections on “How to Put On (Don) PPE Gear” and “How to Take Off (Doff) PPE Gear” that include posters and a video (CDC 2020c).
PPE also includes appropriate eye protection. CDC states “Before entering the patient room or care area, put on eye protection (i.e., goggles or a full face shield that covers the front and sides of the face).” It notes that personal eyeglasses and contact lenses are NOT considered adequate eye protection. If respirators are not available and surgical masks are used, wear a full-face shield.
Clean gloves and gowns are also needed before entering the room.
The CDC guideline (CDC 2020a) also has recommendations on removal, disposal or disinfection of all PPE on leaving the room.
Obviously, strict hand hygiene is required for the whole practice. Hand hygiene should take place before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. Use of alcohol-based hand rub (ABHR) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHR.
Dental healthcare facilities should ensure that hand hygiene supplies are readily available to all dental healthcare personnel in every care location.
But even before PPE, office practice management needs to change to meet the new COVID-19 world. The Indiana Dental Association (Indiana is one of the first states re-opening dental practices) has several practical recommendations (IDA 2020):
CDC has guidelines and recommendations that are updated as needed (CDC 2020a). First, it is important to make sure your own staff does not expose patients or other staff to COVID-19. CDC says “Implement sick leave policies for DHCP that are flexible, non-punitive, and consistent with public health guidance, allowing employees to stay home if they have symptoms of respiratory infection. Ask staff to stay home if they are sick and send staff home if they develop symptoms while at work.”
Next, you need to assess patients for the likelihood that they might be harboring coronavirus. CDC recommends you telephone triage all patients in need of emergency dental care. You should assess the patient’s dental condition and determine whether the patient need to be seen in the dental clinic. Use teleconferencing or teledentistry options as alternatives to in office care. If dental treatment can be delayed, provide patients with detailed home care instructions and any appropriate pharmaceuticals.
If emergency dental care is medically necessary for a patient who has, or is suspected of having COVID-19, airborne precautions (an isolation room with negative pressure relative to the surrounding area and use of an N95 filtering disposable respirator for persons entering the room) should be followed. Dental treatment should be provided in a hospital or other facility that can treat the patient using the appropriate precautions.
Practices should pre-screen patients (with a phone call the day prior to a visit) for symptoms of COVID-19. In addition to the classic symptoms of fever, cough and shortness of breath, CDC has recently updated its list of COVID-19 symptoms and signs to include chills, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell (CDC 2020b). If the patient has symptoms suggestive of COVID-19 they should be referred to their medical provider and perhaps referred to a hospital that has dental capabilities and takes care of COVID-19 patients.
If a patient must be seen in the dental clinic for emergency care, CDC recommends you systematically assess the patient at the time of check-in. The patient should be asked about the presence of symptoms of a respiratory infection and history of travel to areas experiencing transmission of COVID-19 or contact with possible patients with COVID-19. If the patient is afebrile (temperature < 100.4˚F) and otherwise without symptoms consistent with COVID-19, then emergency dental care may be provided using appropriate engineering controls, work practices, and infection control practices.
Some practices will undoubtedly use touchless thermometers to screen patients. But we see problems with that. First, some dental patients, such as those with a dental abscess, may have a fever and not have COVID-19. Second, many patients may be in an asymptomatic phase of COVID-19 yet be capable of shedding virus. So, as below, you need to assume that every patient might be harboring coronavirus and take appropriate safety precautions.
In Japan, dentists will be allowed to take nose and throat swab samples to test patients for the novel coronavirus (Neuman 2020). Allowing onsite testing for COVID-19 in dental practices may be a consideration. However, given that false negative tests may occur, one cannot rely on a single negative test to conclude the patient does not harbor the coronavirus responsible for COVID-19. Just as we adopted universal precautions back when HIV first appeared, we need to assume that every patient might harbor COVID-19 and use the same precautions for all patients.
Social distancing should be practiced in the dental office. You should ensure that patients are able to sit at least 6 feet apart in the waiting area and that also requires that scheduling of patients is such that there will never be more than a set number of patients in the waiting room at one time.
CDC made several revisiions on April 27, 2020 to its guidelines for dental settings (CDC 2020a), including:
All patients should wear facial masks in the waiting area. The dental practice should have masks available for those patients who did not wear their own mask. You also need to have alcohol-based hand sanitizer available in the entrance, waiting area, and any other site where patients or staff should be disinfecting their hands. (Keep in mind that washing hands with soap and water is actually preferable to use of alcohol-based hand sanitizers but soap and water is not practical in the waiting area.) You should also make available tissues and no-touch receptacles for disposal at facility entrances, waiting rooms, bathrooms, and patient check-ins.
If dental care is indicated, CDC recommends certain work practices and certain ones to avoid. For example, you should avoid aerosol generating procedures whenever possible. Avoid the use of dental handpieces and the air-water syringe. Use of ultrasonic scalers is not recommended during this time. Prioritize minimally invasive/atraumatic restorative techniques (hand instruments only). If aerosol generating procedures are necessary, use four-handed dentistry, high evacuation suction and dental dams to minimize droplet spatter and aerosols. The number of dental healthcare personnel present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.
Dental healthcare personnel should wear a facemask at all times while they are in the dental setting. When available, surgical masks are generally preferred over cloth face coverings for dental healthcare personnel because surgical masks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required.
CDC notes that some dental healthcare personnel whose job duties do not require PPE (such as clerical personnel) should continue to wear their cloth face covering for source control while in the dental setting. Other dental healthcare personnel (such as dentists, dental hygienists, dental assistants) may wear their cloth face covering when they are not engaged in direct patient care activities and then switch to a respirator or a surgical mask when PPE is required. Dental healthcare personnel should remove their respirator or surgical mask and put on their cloth face covering when leaving the facility at the end of their shift.
Education of all staff about PPE is important. Dental facilities should provide dental healthcare personnel with training about when, how, and where cloth face coverings can be used including frequency of laundering, guidance on when to replace, circumstances when they can be worn in the facility, and the importance of hand hygiene to prevent contamination. Dental facilities should provide all staff with job-specific training on PPE and have them demonstrate competency with selection and proper use (putting on and removing without self-contamination). Because cloth face coverings can become saturated with respiratory secretions, dental healthcare personnel should take steps to prevent self-contamination, including:
The CDC guideline (CDC 2020a) also has recommendation on cleaning and disinfecting rooms and equipment. Also included are sections on post-exposure guidance and contingency and crisis planning.
The American Dental Association’s Interim Guidance for Minimizing Risk of COVID-19 Transmission (ADA 2020) has sections on:
In addition to state and local health departments, OSHA, CDC and the American Dental Association oversee workplace safety. Remember: before you re-open you need to protect your patients, your staff, and yourselves.
Also note that many of the recommendations above, especially those related to practice management, scheduling, staff training, etc., are also useful for any type of medical practice.
Some of our previous columns on dental patient safety issues:
March 15, 2016 “Dental Patient Safety”
August 2016 “Guideline Update for Pediatric Sedation”
March 28, 2017 “More Issues with Dental Sedation/Anesthesia”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 28, 2017 “More on Dental Sedation/Anesthesia Safety”
July 2019 “Dental Prescribing Called Into Question”
September 2019 “New Guidelines for Pediatric Dental Sedation”
References:
CDC (Centers for Disease Control and Prevention). Coronavirus Disease 2019 (COVID-19). Dental Settings. CDC 2020; April 27, 2020
https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
CDC (Centers for Disease Control and Prevention). Coronavirus Disease 2019 (COVID-19). Using Personal Protective Equipment (PPE). CDC 2020; April 27, 2020
https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html
IDA (Indiana Dental Association). Indiana Dental Association COVID-19 Task Force: Interim Guidance and Recommendations.
https://i6nif33omr43m6n4h1w9uvq8-wpengine.netdna-ssl.com/wp-content/uploads/task-force-guidance.pdf
CDC (Centers for Disease Control and Prevention). Coronavirus Disease 2019 (COVID-19). Symptoms of Coronavirus. CDC 2020; April 27, 2020
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
Neuman S. Japan To Allow Dentists To Conduct Coronavirus Tests. NPR 2020; April 28, 2020
ADA (American Dental Association). ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission. Last Updated: April 1, 2020
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May 12, 2020
Lab Errors and COVID-19
Yes, we told you we were trying to avoid articles on COVID-19 because you are being deluged with them from all sources. But we were looking to do another column on errors related to lab testing and COVID-19 testing happens to provide a great opportunity for that discussion.
In many of our columns on lab errors (most of which actually originate outside the lab) we’ve highlighted works done by European researchers Giuseppe Lippi and Mario Plebani. They recently joined with Ana-Maria Simundic to provide an excellent summary of potential errors that may impact COVID-19 testing and management (Lippi 2020).
In the US there has been a push to increase COVID-19 testing to 5 million tests per day and some have recommended we may need up to 20 million tests per day. Lippi et al. point out that the volume pressures and time pressures involved in such testing increase the vulnerabilities of multiple components of the whole process and are prone to errors.
They note that the generation of false-positive or false-negative test results not only jeopardizes the health of the individual patient, but may also impact the efficacy of public health policies, emergency plans and restrictive measures established by national
and international authorities for containing the pandemic. They note that a false positive result might keep vital workers from their jobs and that a false negative might result in an individual exposing others to COVID-19.
While they acknowledge that there will be multiple forms of testing related to COVID-19, they focus on the current gold standard for the etiological diagnosis of SARS-CoV-2 infection: reverse transcription polymerase chain reaction (rRT-PCR) on respiratory tract specimens. They then provide an overview of the potential preanalytical and analytical
vulnerabilities of RT-PCR testing for diagnosing SARSCoV-2 infection. It’s really a reiteration of all the things we’ve noted that can go wrong with almost any laboratory test (see, for instance, our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error”).
They cite preanalytical and analytical vulnerabilities in RT-PCR testing for diagnosing COVID-19 as below:
Preanalytical
General
Specific
Analytical
Failure to comply with recommended procedures may be a significant cause of diagnostic errors. Examples might include use of wrong swabs, inappropriate absorption of diagnostic material, insertion into inadequate vials, contamination, and others.
In the US there has been a plethora of tests, both for the identification of the virus and for identification of antibodies to the virus. Unfortunately, there has been wide variation in the accuracy, sensitivity, and specificity of the tests and apparently not all have been properly validated. Lippi et al. note that the diagnostic accuracy of many of the currently available RT-PCR tests for detecting SARS-CoV-2 may be lower than optimal. They note that, according to clinical history and serial CT features, 11.6% and 16.6% of all patients with initially negative RT-PCR results were finally considered as probable or highly likely COVID-19 cases. Studies have shown as many as 93% of all patients whose RT-PCR became positive for SARSCoV-19 after an initially negative test result actually had CT features suggestive of COVID-19. In such cases there was a mean interval period of 5.1 days for turning positive.
They note that it’s important to remember that active virus shedding may occur in asymptomatic individuals, in pre-symptomatic individuals (infected individuals before any symptoms or signs have begun), and even for several days after resolution of symptoms in symptomatic individuals. Those are points we reiterated in our May 5, 2020 Patient Safety Tip of the Week “COVID-19 and the Dental Office”, implying that we should approach every patient as if they might be shedding coronavirus.
On the pre-analytical side, it’s important to know how the specimens, especially nasopharyngeal and oropharyngeal swabs, should be collected, managed and stored before testing. Similarly, on the analytical side, assay procedures must be thoughtfully followed, including standard confirmatory testing and test report guidelines, and quality assurance carried out to validate each analytical session. The need for quality assurance is highlighted by an “outbreak” in Thailand of 40 reported positive cases (The Star 2020). Subsequent testing showed that control samples of pure water used at that lab tested positive rather than negative, indicating a problem had occurred in the process.
Other technical and analytical issues include instrument malfunctioning (including inappropriate PCR cycling conditions), use of insufficient or inadequate material, non-specific annealing of PCR to homologous sequences, misinterpretation of expression profiles and others.
Note, however, that the current article by Lippi et al. leaves out an important source for error that we discussed in our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error” – namely the post-analytic phase or what happens once the result is reported to the ordering clinician. There is plenty that can go wrong at and after that step. See that column for the sorts of errors that can occur in:
These steps are all important components of “closing the loop”
Also, Step 2 in our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error” dealt with ordering the test in the first place. One question, in particular, is “Was the correct test ordered?”. Pertaining to COVID-19 there is a myriad of diagnostic tests out there. The Lippi article focuses on the PCR testing and does not address antibody testing. So, you need to consider what you are looking for and where in the natural history of COVID-19 infection your patient might be. A great summary of COVID-19 diagnostic tests was just published (Sethuraman 2020) and includes a graph that nicely outlines the timeframes for specific tests in relation to onset of symptoms. So, knowledge of the natural history of COVID-19 is important. In addition to that graph, the Lippi article notes that the incubation period of SARS-CoV-2 is around 6 days (interquartile range 2–11 days), the median period between symptom onset and hospital admission is 7 days (IQR, 4–8 days), median period of symptom duration around 13 days (IQR, 5–24 days) and slightly longer in patients with severe disease (16 days; IQR, 10–20 days).
Context is everything. That means you should not interpret the result without considering the entire clinical picture. Lippi et al. advise that the most efficient strategy for diagnosing COVID-19 in suspected patients should encompass a combination of SARS-CoV-2 RT-PCR with clinical and epidemiologic evidence (probability of exposure, signs, symptoms, negative diagnostic tests especially for other respiratory illnesses) and chest CT findings. Repeated respiratory specimens should be collected (daily or, at least, every other day) and tested by RT-PCR in patients with initially negative results but high suspicion (or probability) of having COVID-19.
The FDA cautions that the risks to a patient of a false negative include: delayed or lack of supportive treatment, lack of monitoring of infected individuals and their household or other close contacts for symptoms resulting in increased risk of spread of COVID-19 within the community, or other unintended adverse events (FDA 2020).
False positives, of course, can also have adverse consequences, such as inappropriate treatment, unnecessary quarantine, or unnecessary hospitalization. An unexpected spike in positive tests should lead to checking for confirmation, as evidenced by the case in Thailand alluded to above where 40 reported positive cases were determined to be false positives (The Star 2020).
And. on the antibody testing side, there also remain significant issues. Some of the tests currently available simply identify that antibodies are present and don’t quantify them. In addition, it is not known what titre of antibodies, if any, conveys immunity against COVID-19 and for how long if it does. There has also been some concern raised that antibodies in some cases may actually represent cross-reactivity against other coronaviruses rather than the COVID-19 virus (Whyte 2020). So, for the time being, it remains unclear what a positive antibody test means in practical terms.
The current article by Lippi et al. uses issues related to COVID-19 but is really an excellent reminder of the vulnerabilities we encounter in almost any laboratory test. It reiterates the many problems related to lab studies that we’ve highlighted in our previous columns listed below. Remember: most lab errors occur outside the lab, but errors may be seen in the pre-analytical, analytical, and post-analytical phases of laboratory diagnosis.
Some of our other columns on errors related to laboratory studies:
See also our other columns on communicating significant results:
See also our other columns related to COVID-19:
References:
Lippi G, Simundic A, Plebani M. Potential preanalytical and analytical vulnerabilities in the laboratory diagnosis of coronavirus disease 2019 (COVID-19), Clinical Chemistry and Laboratory Medicine (CCLM) 2020; published online ahead of print, 20200285
The Star. Lab cleared after result error. The Star (Thailand) 2020; May 7, 2020
https://www.thestar.com.my/news/regional/2020/05/07/lab-cleared-after-result-error
Sethuraman N, Jeremiah SS, Ryo A. Interpreting Diagnostic Tests for SARS-CoV-2. JAMA 2020; Published online May 06, 2020
https://jamanetwork.com/journals/jama/fullarticle/2765837
FDA (US Food and Drug Administration). Fact Sheet for Healthcare Providers. New York SARS-CoV-2 Real-time RT-PCR Diagnostic Panel. FDA 2020; Updated: March 15, 2020
https://www.fda.gov/media/135662/download
Whyte J, Saag M. Hold on Antibody Testing: 'The FDA Has Done Us a Disservice'. Medscape Medical News 2020; May 06, 2020
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May 19, 2020
Reminder on Telephone or Verbal Orders
It’s well accepted that verbal orders or telephone orders are potentially prone to error. That’s why we always recommend avoiding them whenever possible. But sometimes use of such orders is unavoidable, such as when the clinician is in the OR or attending to an emergency in a different area. Unfortunately, the current COVID-19 pandemic has created circumstances where there has been an increased need to provide orders verbally or via telephone. When the ordering clinician is offsite we still recommend he/she use CPOE whenever possible (via remote access). Orders given via CPOE make use of proper terminology, use clinical decision support tools, and typically remind the clinician of all parameters needed for a proper order.
But when there is no alternative, it’s important to ensure that both the ordering clinician and the receiving party (nurse, pharmacist, etc.) properly convey all the elements of the verbal or telephone order.
ISMP Canada (ISMP Canada 2020) recently published a safety bulletin on safety issues with telephone or verbal orders. That bulletin begins with a report about a miscommunication in a telephone order for hydromorphone that led to dispensing of the oral liquid formulation instead of the intended injectable formulation. The oral product was injected by a home care nurse, which resulted in harm to the patient.
ISMP Canada reminds us to allow sufficient time to state the order clearly and for the person receiving it to read it back. The ordering clinician should state his/her name, license number, and contact information. Say and then spell out the patient’s name and provide a second identifier (e.g., address, birth date). Note that the ordering clinician should have some way of knowing the patient’s full name and second identifier. But there is some important information the ordering clinician may not have readily at hand, such as the patient’s allergies, the patient’s weight, and the full list of the other medications the patient is taking. The person receiving the verbal order may have access to that information and provide it to the ordering clinician.
Next, incorporate all the elements of a complete medication order, including drug name, dosage form, dose and strength (if applicable), route of administration, directions for use, and quantity to be dispensed and/or duration of therapy. For prescriptions that are given to community pharmacies, also provide the number of refills and/or the refill interval.
Two extremely important concepts for verbal or telephone orders are: spell out and read back. ISMP Canada recommends drug names be communicated by first saying and then spelling them out. Both the generic and brand names should be provided, especially for recognized look-alike, sound-alike medication pairs. It may be helpful to use a phonetic alphabet to distinguish between sound-alike letters (e.g., “m” as in Mary or “n” as in Nancy). Numbers should be communicated using two different approaches. For example, because the number 15 can easily be misheard as 50, a prescription for “15 mg” should also be communicated as “one-five-milligrams”.
Abbreviations should be avoided. For example, replace “BID” with “twice a day”, and replace “PO” with “by mouth” or “orally”. They also noted that the patient’s weight should be included for pediatric patients and for all weight-based medication orders.
“Read back” is arguably the most important facet of any verbal or telephone order. The person receiving the order reads back the entire order, slowly and distinctly. The same techniques described above for using a phonetic alphabet to distinguish between sound-alike letters and specifying numbers one digit at a time should be adhered to. The receiver should then request confirmation from the prescriber that the read-back matches the intended order. Any ambiguous aspects of the prescription or order should be clarified by both.
The ISMP Canada guideline emphasizes a point we harp on over and over – providing the indication for a medication is a very useful safety tool. See our August 2019 What's New in the Patient Safety World column “Including Indications for Medications: We Are Failing” for a discussion of that issue. ISMP Canada says you should explicitly state the indication for the drug, to reduce the risk of misinterpretation.
ISMP Canada notes you should obtain the prescriber’s name, license number, and contact information at the start of the call. We do like the ISMP Canada requirement of obtaining the contact information of the ordering clinician. It’s critical that staff know how to get hold of that clinician in the event that questions about the order arise following the initial phone call.
They recommend the order be immediately transcribed or entered into its permanent record (e.g., patient chart, pharmacy hard copy and/or profile) to facilitate accurate documentation of the prescription. Delaying this documentation step can contribute to erroneous transcription. ISMP in the US has also recommended verbal orders should be immediately transcribed into the patient’s medical record or onto a prescription pad as they are being communicated (ISMP 2017). They note that transcription from scrap paper to the medical record introduces another opportunity for error. But they note there may be challenges to directly entering verbal orders into an electronic health record. When a nurse or pharmacist is allowed to enter such orders into the EMR, we recommend that the ordering clinician remain available as those orders are entered, since there may be alerts or other clinical decision supports that pop up during order entry that need to be addressed. For order clarifications by a pharmacist, a mechanism should be provided for the pharmacist to transcribe the orders directly into the patient’s medical record.
The person receiving the telephone or verbal order, of course, needs to be someone whose scope of practice allows them to receive orders. Your bylaws and rules and regulations should clearly spell out who can receive these orders and what types of orders they can receive. Usually the receiver is a nurse or pharmacist. But there might be some types of orders that could be received by a respiratory therapist or physical therapist or others.
Most hospitals are woefully inadequate regarding security measures for telephone orders. After we’ve witnessed a nurse taking a telephone order, we often ask that nurse “How did you know who was giving you that order?”. The usual response is “Well, I know his/her voice.”
We use at least 2-factor identification for patients. Why wouldn’t we demand at least that much for identification of a clinician providing a telephone order? The ISMP Canada bulletin suggests obtaining the ordering clinician’s name and license number (as well as contact information) at the start of a call. We don’t like using the license number. It is too easy to find that license number. Someone posing as that clinician can usually find his/her license number either online at the state health department website or from the license/registration that many states require be posted in the clinician’s office. An alternative is for each hospital to assign a special code (akin to the PIN you use at ATM’s) to each clinician for use in such phone calls. (It would be more difficult to assign codes for each community pharmacy given that a clinician is likely to have patients using many different pharmacies.)
In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we note there have been reports (ISMP 2008) of several instances of fraudulent orders. In one a teenager who worked at the hospital who began answering pages to on-call residents. He issued orders for 6 patients (lab tests, oxygen orders, heparin orders) that were not caught right away because the orders were medically “appropriate”. Another case involved a friend of a patient with AIDS calling in a verbal order for insulin in apparent attempt to end that patient’s life. And another case where someone posing as a physician ordered enemas on six different patients. The ISMP article suggested several things you can do to avoid such fraudulent telephone orders. If you don't recognize the caller, request his or her telephone number, verify it in the medical staff directory, and call the prescriber back to take the order. You can also verify a cell phone number with the prescriber's office staff or answering service. Another identification method is asking for a doctor-specific number such as medical records dictation number, but you'd need a list of these numbers to verify the caller's identity. If the caller doesn't provide a telephone number or you can't verify it, ask the individual to call back to speak to a nursing supervisor.
Are there some orders that should be “off limits” for telephone orders? You’ve heard us tell the story about the resident who ordered (from his oncall room) a neuromuscular blocking agent for a patient, not realizing that the patient was not intubated and being mechanically ventilated. There could be unintended consequences of totally barring such orders but you could, at a minimum, require that certain orders (eg. for NMBA’s, opiates, etc.) would require a second person verify the order. You probably should prohibit verbal or telephone orders for chemotherapy (other than those to hold or discontinue chemotherapy) because these are seldom emergent and the complex dosing of such medications makes them even more error-prone (ISMP 2017). ISMP also recommends limiting verbal/telephone orders to formulary drugs (ISMP 2017). That’s because the names and dosages of drugs unfamiliar to practitioners are more likely to be misheard.
The ISMP Canada bulletin is not the only recent one reminding us of the dangers of verbal and telephone orders. In our April 2020 What's New in the Patient Safety World column “More Gems from ISMP” we noted ISMP’s Top 10 Medication Errors and Hazards for 2020 (ISMP 2020). Number 4 on that list is “Misheard drug orders/recommendations during verbal/telephone communication”. It recommended reserving verbal or telephone orders for use only during an emergency or when the provider is working in a sterile environment. It noted the importance, when verbal orders are necessary under those conditions, the receiver should READ BACK (or repeat back during sterile procedures) the drug therapy (drug, dose, route, frequency), SPELLING the drug name, and stating the dose in single digits (e.g., one-five for 15).
A 2017 survey by ISMP had some disturbing findings (ISMP 2017). While most verbal orders were given via telephone or face-to-face, there were instances of verbal orders being left on voicemail. And respondents noted that up to 25-50% of orders were verbal orders! Nearly half (45%) of all respondents who reported receiving telephone or spoken orders said they do readback less than 50% of the time. 16% of respondents said they read back verbal orders only 1-5% of the time, and 9% indicated they never carry out this important verification process. 14% of respondents were aware of an error that occurred in the past year due to mishearing, misunderstanding, or incorrectly transcribing verbal orders
In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we listed the important things pertinent to verbal and telephone orders you need to ensure take place via your policies, procedures and practices. They are still, remarkably, applicable:
That last point is important. If your audit finds that there is an unacceptably high frequency of verbal or telephone orders in your organization, you need to find out why. For example, in a previous column we noted a hospital found a very high percentage of transfusion orders were being given as verbal orders. When analyzed, it became apparent that the order entry process for transfusions was so onerous that it was easier for the ordering clinician to just do a verbal order.
In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we mentioned one of the only systematic studies addressing the issue (West 1994) failed to demonstrate that that verbal orders were more error-prone. In fact, in that study verbal orders were actually less error-prone than written or computerized orders!! They did note, however, that verbal orders became more prone to error as the orders became more complex.
Could that prior study showing that verbal orders are actually less error-prone (West 1994) have been true? There are at least some theoretical and practical reasons that verbal orders might, in fact, be less error-prone. A nurse transcribing orders does not have to decipher the handwriting of a physician on written orders. Similarly, the artifacts often seen with faxed orders (eg. “missing” decimal points, etc.) don’t come into play with verbal orders. And the nurse (or pharmacist) taking the verbal order has the opportunity to clarify the order more easily than with written orders. And the types of orders given verbally tend to be less complex. So maybe, despite our suspicions to the contrary, they could be less error-prone. That, of course, does not mean we should not have policies, procedures and practices for dealing with verbal/telephone orders to make sure that verbal/telephone orders are as safe as possible. We’d all like to think that with the widespread implementation of computerized physician order entry (CPOE) the need for verbal or telephone orders will be eliminated. That, however, is extremely unlikely. There are always likely to be situations in settings such as the OR, ER, ICU, sterile procedure rooms, etc. where a provider is tied up attending to one patient’s needs and an urgent order is needed on another patient. And even where we make CPOE available remotely to physicians not on site, there will be times when the systems are unavailable.
Of course, that brings us to another of our annual rants: don’t text orders! And we don’t like faxed orders! See our many columns on texted orders and faxed orders listed below.
See our other Patient Safety Tip of the Week columns dealing with texting:
See our prior columns on problems related to use of fax in healthcare:
References:
ISMP Canada Strategies for Safer Telephone and Other Verbal Orders in Defined Circumstances. ISMP Canada Safety Bulletin 2020; 20(4): 1-2 May 7, 2020
https://www.ismp-canada.org/download/safetyBulletins/2020/ISMPCSB2020-i4-TelephoneOrders.pdf
ISMP (Institute for Safe Medication Practices). Despite Technology, Verbal Orders Persist, Read Back is Not Widespread, and Errors Continue. ISMP Medication Safety Alert! Acute Care Edition 2017; May 18, 2017
Institute for Safe Medication Practices (ISMP). Telephone orders. How do you know the caller is for real? ISMP Nurse Advise-ERR 2008; 6(7): 2 (July 2008)
http://www.ismp.org/newsletters/nursing/Issues/NurseAdviseERR200807.pdf
ISMP (Institute for Safe Medication Practices). Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards. ISMP 2020; January 16, 2020
West DW, Levine S, Magram G, et al. Pediatric Medication Order Error Rates Related to the Mode of Order Transmission. Arch Pediatr Adolesc Med 1994; 148(12): 1322-1326
https://jamanetwork.com/journals/jamapediatrics/article-abstract/517400
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May 26, 2020
Early Warning Scores
It’s been 2 years since our last column on early warning scores for early recognition of clinical deterioration. But last week, just days apart, there were 2 published reviews of early warning scores.
The concept behind early warning scores is simple. Scanning readily collected physiologic data, usually utilizing computer algorithms, can spot trends suggesting clinical deterioration that might otherwise not be recognized at an early stage where intervention might be useful.
Our previous columns, listed below, have highlighted both successes and failures of early warning scores, as well as the successes and failures of the rapid response interventions designed to rescue patients having signs of clinical deterioration.
Liu and colleagues (Liu 2020) retrospectively applied 5 commonly used early warning tools to data collected on a large cohort of adult inpatients outside the ICU in two states. The 5 tools were the National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Between the Flags (BTF), Quick Sequential Sepsis-Related Organ Failure Assessment (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS). They also stratified results based upon whether the patients had suspected infection or not. The authors acknowledge that SIRS and qSOFA were not developed as early warning scores for all patients. They were specifically developed for assessing patients for sepsis, but many hospitals have utilized them for early warnings.
Assessing the area under the receiver operating characteristic curves (AUCs), they found the NEWS exhibited the highest discrimination for mortality (AUC 0.87 and 0.86 in California and Illiniois, respectively), followed by the MEWS (AUC’s 0.83 and 0.84), qSOFA (AUC’s 0.78 and 0.78), SIRS (AUC’s 0.76 and 0.76), and BTF (AUC’s 0.73 and 0.74).
A similar pattern was seen in the suspected infection cohort, with the NEWS demonstrating the highest AUC for both outcomes across both states, followed by the MEWS. Even among patients with infection, the discrimination of the NEWS and MEWS were higher in all cases than the infection-specific risk scores.
The authors conclude that, for the goal of detecting clinical deterioration in hospitalized, non-ICU patients, aggregate weighted risk scores, such as those determined with NEWS and MEWS, outperform infection-specific scores, even among patients with suspected infection.
We’ve always been biased against use of SIRS. When Medicare and other third party payers used SIRS criteria to allow for coding for a diagnosis of sepsis, we saw an interesting phenomenon: mortality for both sepsis and pneumonia decreased. Why? We would see a patient with pneumonia happily pushing his IV pole as he walked up and down the hallway on a typical med-surg floor. But because he met 2 of the SIRS criteria, the clinical documentation specialists that many hospitals contracted with, would recommend coding that patient as “sepsis”, hardly what we clinicians would have called sepsis in the past. The result was that patients not likely to die (like the one mentioned above) were now included with all patients with “sepsis”, diluting out that population that might have previously had a high mortality rate. Similarly, patients with pneumonia who might have had a high mortality rate were now moved to the sepsis category, reducing the overall “pneumonia” mortality rate.
But the Liu study found the scores of most of the early warning systems were good predictors of mortality. On the other hand, for the combined outcome of ICU transfer or death discrimination was only poor to adequate. That of course, is important because the goal of early warning systems is to improve the identification of high-risk patients and enable clinical interventions that can mitigate or prevent deterioration, including proactive transfer to the ICU.
That brings us to the second publication. Gerry and colleagues (Gerry 2020) performed a systematic review and critical analysis of early warning score tools and found that, despite their widespread use, many early warning scores in clinical use were found to have methodological weaknesses.
Death was the most frequent prediction outcome for development studies and validation studies, with different time horizons (the most frequent was 24 hours). The most common predictors were respiratory rate, heart rate, oxygen saturation, temperature, and systolic blood pressure. Age and sex were less frequently included. They found that key details of the analysis populations were often not reported in development studies or validation studies and small sample sizes and insufficient numbers of event patients were common. Moreover, missing data were often discarded. Only nine of the early warning scores that were developed were presented in sufficient detail to allow individualized risk prediction. All included studies were rated at high risk of bias.
The authors note that many of the early warning scoring systems were originally developed in the paper-based chart era and scores were calculated manually, necessitating simple scoring systems. They point out that points were often assigned equally to each vital sign, assuming that each vital sign has the same predictive value, which may not be the case. That may result in a total score that has little meaning. They do note that the move to computerized algorithms and machine learning has the potential to improve early warning systems. Many of the barriers to success of early warning systems that we discussed in our July 15, 2014 Patient Safety Tip of the Week “Barriers to Success of Early Warning Systems” had to do with manual data collection and computation of scores. Our November 11, 2014 Patient Safety Tip of the Week “Early Detection of Clinical Deterioration” described how use of wireless handheld computing devices to replace a paper-based vital sign charting and use of computerized tools led to early recognition of and response to patient deterioration, resulting in improved mortality rates. Several of our other columns have discussed EMR-based early warning scores with good predictability, especially for early identification of sepsis and septic shock (see our Patient Safety Tip of the Week for September 8, 2015 “TREWScore for Early Recognition of Sepsis” and our What's New in the Patient Safety World columns for October 2015 “Even Earlier Recognition of Severe Sepsis” and June 2016 “An EMR-Based Early Warning Score”).
Gerry et al. end with recommendations for approaches for developing and evaluating early warning scores and investigating the impact and safety of using these scores in clinical practice.
And our February 2015 What's New in the Patient Safety World column “Detecting Clinical Deterioration: Don’t Neglect Clinical Impression” reminded us not to neglect the value of the clinical impression a nurse or physician has about the patient’s status. In that column we noted a study that added the question “How likely is this patient to suffer a cardiac arrest or require emergent transfer to the ICU in the next 24 hours?” improved the predictive value of at least one early warning system tool (Patel 2015).
And, of course, the success or failure of any early warning system depends upon what you do with it. Our multiple columns listed below demonstrate the mixed outcomes of rapid response teams and rapid response systems.
Bottom line: early warning scoring systems and our programs to respond to such warnings still have opportunity for improvement. But the concepts remain good and we should not abandon efforts to build upon work already done.
Some of our other columns on MEWS or recognition of clinical deterioration:
Our other columns on rapid response teams:
References:
Liu VX, Lu Y, Carey KA, et al. Comparison of Early Warning Scoring Systems for Hospitalized Patients With and Without Infection at Risk for In-Hospital Mortality and Transfer to the Intensive Care Unit. JAMA Netw Open 2020; 3(5): e205191
Gerry Stephen, Bonnici Timothy, Birks Jacqueline, Kirtley Shona, Virdee Pradeep S, Watkinson Peter J et al. Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology BMJ 2020; 369 :m1501
https://www.bmj.com/content/369/bmj.m1501
Patel AR, Zadravecz FJ, Young RS, et al. The Value of Clinical Judgment in the Detection of Clinical Deterioration. JAMA Intern Med 2015; 175(3): 456-458 Published online January 05, 2015
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2087874
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June 2, 2020
Perioperative Hypothermia
Perioperative hypothermia is a common complication of orthopedic surgery that is associated with increased morbidity, including increased risk for surgical site infections, sepsis, increased bleeding risk, cardiac and other complications, mortality and prolonged length of stay.
A 2018 review of almost 7,000 orthopedic cases (Kleimeyer 2018) found hypothermia in 72.5% of patients intraoperatively and 8.3% postoperatively. Risk factors for postoperative hypothermia included intraoperative hypothermia (odds ratio 2.72), lower preoperative temperature (OR 1.46), female sex (OR 1.42), lower body mass index (OR 1.06 per kg/m2), older age (OR 1.02 per year), adult reconstruction by specialty (OR 4.06), and hip and pelvis procedures by anatomic region (OR 8.76).
Another 2018 review (Boddu 2018) noted risk factors that can contribute to inadvertent perioperative hypothermia can be subdivided into 3 groups: patient-related risk factors, anesthesia-related risk factors, and procedure-related risk factors.
Patient-related risk factors identified were a high severity of illness on admission (OR 2.81), presence of a neurological disorder such as Alzheimer’s disease (OR 1.71), male sex (OR 1.65), age >65 years (OR 1.61), recent weight loss (OR 1.60), anemia (OR 1.49), and chronic renal failure (OR1.43).
They note that the effects of general and regional anesthesia on perioperative core temperature are significantly different, both in terms of intraoperative thermoregulation and postoperative recovery. Core body temperature drops during the first 2 hours of general anesthesia, due to loss of thermoregulatory cutaneous and peripheral vasoconstrictive responses resulting in heat loss exceeding metabolic heat production but then plateaus during the subsequent 3 hours due to the return of the thermoregulatory responses. Notably, postoperative recovery from the hypothermia induced by general anesthesia is significantly faster than from that induced by regional anesthesia.
The effects of regional anesthesia and regional hypothermia are complex and depend upon whether a tourniquet is used or not. The extent and rate of development of peripheral/limb hypothermia and core body temperature during surgery depends on several factors, including the operating room ambient temperature, duration of tourniquet application, and temperature of any irrigation fluid. They note that postoperative recovery from the hypothermia induced by regional anesthesia takes longer than from that induced by general anesthesia because of the prolonged period of loss of vasoconstrictive response.
Procedure-specific risk factors for inadvertent perioperative hypothermia during arthroscopic surgery include prolonged operating time, low blood pressure during the procedure, and low temperature of the irrigation fluid.
The authors note that ambient operating room temperature has traditionally been considered a risk factor for inadvertent hypothermia in perioperative patients, but that evidence for that was scant or even contradictory.
They discuss both active and passive interventions to avoid hypothermia. Passive methods decrease heat loss by radiation (eg, reflective blanket), conduction (eg, layered cotton blankets and padding the operating table), or convection (eg, heat and humidity exchanger in the breathing circuits) to the surrounding environment. Active patient heating methods are generally more successful and aim to bring in heat from the source to the patient’s body using conduction (eg, Hot Dog® [Eden Augustine Temperature Management]) or convection (eg, Bair Hugger® [Arizant Healthcare]) techniques.
Simpson et al. (Simpson 2018) found that, at the time of incision, 60 of 179 (34%) total knee arthroplasty (TKA) patients and 80 of 204 (39%) total hip arthroplasty (THA) patients were hypothermic. In THA patients, 65% remained hypothermic for the duration of anesthesia compared to 33% of TKA patients. The largest drop in core body temperature in both THA and TKA patients occurred between preoperative holding and induction of anesthesia. In THA patients, spinal anesthesia had a significantly higher occurrence of PH. No significant patient factor was found to increase risk. The authors suggested that emphasis on preoperative holding protocols, decreasing time from operating room entry to incision, and increasing ambient room temperature could reduce risk of hypothermia in this patient population.
Though not confined to orthopedic cases, another study (Akers 2019) found 7 of 298 surgical patients at a single hospital site in the midwestern United States were hypothermic in the post-op period. Older adults (ie, more than 60 years old) were significantly more likely to experience hypothermia and that abdominal procedures posed a greater risk for hypothermia than other procedures. In addition, perioperative hypothermia was significantly associated with postoperative anemia, sepsis, and mortality.
The type of anesthesia did not significantly differ between the hypothermic and normothermic groups. Although multiple combinations of anesthesia (eg, general anesthesia used in conjunction with spinal anesthesia) were noted in the total sample, general anesthesia was used exclusively for most procedures and all seven patients who experienced perioperative hypothermia received general anesthesia only. Some previous studies had suggested hypothermia was more common in patients undergoing combination anesthesia. Also, contrary to some other studies, duration of surgery did not appear to correlate with hypothermia.
Another recent study (Nordgren 2020) compared the efficacy of four treatment interventions to prevent hypothermia in patients undergoing total knee or hip arthroplasty. The interventions included convective warming (ie, forced air warming or FAW) with prewarming (group 1), conductive warming with prewarming (group 2), reflective and convective warming without prewarming (group 3), and convective warming only (group 4). There were 30 patients in each group. They also standardized anesthetic agents and delivery methods, administering spinal anesthetic blocks of 15 mg of bupivacaine with 45 μg of clonidine or general anesthesia. They also agreed to avoid the use of sedating agents whenever possible, but if sedation was required, they administered 1 to 2 mg of midazolam.
The mean temperature decreased in all groups upon arrival in the OR and after the administration of anesthesia. At the beginning of surgery, the mean temperature fell below the hypothermic limit for all patients in groups 2, 3, and 4. During surgery, there was an increase in core temperature for all interventions. However, upon the patient’s arrival to the PACU, the mean temperature fell below the hypothermic limit for all interventions.
The average number of inadvertent perioperative hypothermia (IPH) episodes for group 1 was significantly lower compared with the number of IPH episodes for groups 2, 3, and 4.
There was no difference in the perception of cold or warmth between groups and, interestingly, none of the patients felt uncomfortable. This point further emphasizes the need to measure core temperature objectively in such patients.
Patients using a FAW gown who began prewarming on the nursing unit had a significantly higher core temperature throughout the perioperative period. These patients had a lower rate of IPH than patients who received the other three interventions.
The authors felt that, although the active self-warming blanket was less effective than FAW at preventing IPH, the active self-warming blanket may still be beneficial because it can be used during patient transport without a control unit.
Many patients using the handheld controller for the FAW expressed a positive feeling of control over something preoperatively and postoperatively; this seemed to be an additional patient benefit.
The study confirms that inadvertent perioperative hypothermia is common in patients undergoing THA or TKA. It suggests that convective warming (ie, FAW) with prewarming appears to reduce hypothermia in patients. Prewarming with an active self-warming blanket (ie, conductive warming) was less effective. An important finding that merits further research is that patients’ temperatures typically drop after they leave the OR and arrive in the PACU
Our January 23, 2018 Patient Safety Tip of the Week “Unintentional Hypothermia Back in Focus” discussed three articles showing that unintentional hypothermia is very common in obstetrics, but lamented the relative lack of proven interventions to prevent or treat hypothermia in obstetrical patients.
Note that a previous Cochrane review (Cochrane 2014) found that active warming, particularly forced air warming, appears to offer a clinically important reduction in mean time taken to achieve normothermia in patients with postoperative hypothermia, but that high-quality evidence on other important clinical outcomes is lacking. It concluded that it is unclear whether active warming offers other benefits and harms. High-quality evidence on other warming methods is also lacking; therefore, it is unclear whether other rewarming methods are effective in reversing postoperative hypothermia.
So, are there harms associated with various warming interventions? Several of our prior columns on iatrogenic burns (listed below) cited cases of burns caused by warming blankets and other warming devices. In particular, our December 23, 2014 Patient Safety Tip of the Week “Iatrogenic Burns in the News Again” gave details on the additional risk factors that may have predisposed such patients to burns, such as poor tissue perfusion, sensory loss, etc. It also discussed the dangers of “hosing” or “free-hosing” (using the hose of the warming device without the blanket attachment and allowing the hot air to blow directly onto the patient, forcing the hot air onto one focused area of the body).
In that column we made the following recommendations to avoid thermal injuries from warming blankets and related devices:
Our own interest in unintentional hypothermia was related to occurrence of an unusual phenomenon in patients undergoing spinal anesthesia using morphine. These were cases (most often obstetrical) in which spinal anesthesia with morphine is used and patients develop hypothermia with paradoxical sweating. See our Patient Safety Tips of the Week for December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist” and January 23, 2018 “Unintentional Hypothermia Back in Focus” for details. The proposed mechanism is that enough of the morphine ascends in the subarachnoid space to reach the hypothalamus where it interacts with receptors important in thermoregulation. Essentially this leads to alteration of the hypothalamic thermoregulatory set point causing the body to feel hot and sweat in attempt to adapt to heat. The main reason to recognize that phenomenon is that some cases appear to respond to benzodiazepines. Benzodiazepine receptors are also found in the hypothalamus and are probably also involved in thermoregulation. Naloxone and atropine have also been noted to produce improvement in case reports. You probably should amend your hypothermia management protocols to take this phenomenon into account. Specifically, there should be a prompt to consider the phenomenon if the expected improvement in hypothermia is not occurring within a reasonable amount of time after conventional warming procedures have been instituted. Perhaps even a prompt at the beginning of your protocol to look for signs you would not expect with hypothermia (i.e. sweating, hot feeling, vasodilation) might suggest this unusual etiology for the hypothermia. The presence of nausea and pruritis might be an additional clue. In either case the prompt should remind you to consider a trial of either low dose benzodiazepine or naloxone.
Your facility should have a formal protocol to follow for prevention and management of perioperative hypothermia. The AORN Guideline for Prevention of Hypothermia (AORN 2020) was also discussed in a recent review (Link 2020), stressing use of a consistent temperature measurement method through all phases of perioperative care, assessing risk for hypothermia in all patients, and prewarming perioperative patients. Other guidelines and resources on perioperative hypothermia are available from the Pennsylvania Patient Safety Authority (PPSA 2008), the American Society of PeriAnesthesia Nurses (ASPAN 2010), and the National Institute for Health and Care Excellence (NICE 2017).
Our prior columns on inadvertent perioperative hypothermia:
Our prior columns on iatrogenic burns:
References:
Kleimeyer JP, Harris AHS, Sanford J, et al. Incidence and Risk Factors for Postoperative Hypothermia After Orthopaedic Surgery. J Am Acad Orthop Surg 2018; 26(24): e497-e503
Boddu C, Cushner J, Scuderi GR. Inadvertent Perioperative Hypothermia During Orthopedic Surgery. Am J Orthop (Belle Mead NJ). 2018; 47(7): Publish date: July 12, 2018
Simpson JB, Thomas VS, Ismaily SK, et al. Hypothermia in Total Joint Arthroplasty: A Wake-Up Call. Journal of Arthroplasty 2018; 33(4): 1012-1018, April 01, 2018
Published: November 07, 2017
https://www.arthroplastyjournal.org/article/S0883-5403(17)30969-5/pdf
Akers JL, Dupnick AC, Hillman EL, et al. Inadvertent Perioperative Hypothermia Risks and Postoperative Complications: A Retrospective Study. AORN Journal 2019; 109(6): 741-747
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12696
Nordgren M, Hernborg O, Hamberg A, et al. The Effectiveness of Four Intervention Methods for Preventing Inadvertent Perioperative Hypothermia During Total Knee or Total Hip Arthroplasty. AORN Journal 2020; 111(3): 303-312 First Published:04 March 2020
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12961
Cochrane Review. Treating unintentional hypothermia after surgery. Cochrane.org 2014
http://www.cochrane.org/CD009892/ANAESTH_treating-unintentional-hypothermia-after-surgery
AORN (Association of periOperative Registered Nurses). Guideline for prevention of hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2020: 327-356
https://www.aorn.org/guidelines
Link T. Guidelines in Practice: Hypothermia Prevention. AORN Journal 2020; 111(6): 653-666 First Published:28 May 2020
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13038
PPSA (Pennsylvania Patient Safety Authority). Prevention of Inadvertent Perioperative Hypothermia. Pa Patient Saf Advis 2008; 5(2): 44-52
http://patientsafety.pa.gov/ADVISORIES/Pages/200806_44.aspx
ASPAN (American Society of PeriAnesthesia Nurses). Normothermia Clinical Guideline. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia.
http://www.aspan.org/Clinical-Practice/Clinical-Guidelines/Normothermia
NICE (National Institute for Health and Care Excellence). Inadvertent perioperative hypothermia overview. NICE Pathway 2017; Update 29 March 2017
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June 9, 2020
Perioperative Medication Safety
Medication safety is a primary concern in almost every venue of our healthcare delivery system. But the OR and the perioperative period have unique circumstances that increase the vulnerability for medication errors. Common factors predisposing to medication errors in this environment are:
Probably the most telling story about perioperative medication safety was a study from the Massachusetts General Hospital (Nanji 2015) that we discussed in our November 3, 2015 Patient Safety Tip of the Week “Medication Errors in the OR - Part 2”. 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.
A recent AORN review (Spruce 2020) of perioperative medication safety identified several other factors contributing to medication errors in the perioperative environment:
The Spruce review further notes that pediatric patients undergoing surgery are at an increased risk for medication errors because of weight-based dosing calculations and dilutions.
Among the recommendations in the Spruce review:
One of the biggest vulnerabilities to serious medication errors in the OR is related to maintenance of the sterile field. Medications transferred to the sterile field are sometimes drawn from unlabeled containers or are in syringes that are unlabeled. In addition, the presence of multiple syringes in the sterile field may lead to syringe “swapping” errors. A recent review of incorrect administration of neuromuscular blocking agents (NMBA’s) during spinal or epidural anesthesia (Patel 2020) found syringe swap was the primary cause for the majority of errors. Unlabeled syringes were one factor in accidental spinal injections discussed in our July 9, 2019 Patient Safety Tip of the Week “Spinal Injection of Tranexamic Acid”.
The Spruce review has good recommendations to avoid medication errors related to the sterile field:
The Spruce review also discusses precautions that must be taken if any medications must be compounded or multiple medications mixed.
Regarding handoffs, medication reconciliation needs to take place at all transitions of care. That includes transitions like transfer from the pre-op area to the OR, from the OR to the PACU, from the PACU to the ICU or med/surg unit. It’s especially important to pay attention to any IV lines that may be connected to sources of medications. A good checklist for such transitions of care would contain an item about checking those IV lines. Note that transitions of care apply not only to transfers of the patient from one location to another. In fact, the staff may change in the OR itself (for example, nursing staff or anesthesiology staff may occasionally change in cases of long surgical duration). Those transitions are also vulnerable periods for medication errors as well as other errors. And don’t forget that the medication reconciliation must extend beyond just the last transition of care. For example, many medications are withheld prior to anticipated surgery and need to be restarted after completion of the surgery and PACU recovery period.
Just as elsewhere in the healthcare system, look-alike sound-alike (LASA) issues may lead to medication errors in the OR. Given the stresses, time pressures, distractions and interruptions commonly occurring in the OR setting, it is not surprising that someone may grab an incorrect vial that has an appearance similar to the intended one. Similarity of ampules of tranexamic acid and local anesthetic agents were a factor in accidental spinal injections discussed in our July 9, 2019 Patient Safety Tip of the Week “Spinal Injection of Tranexamic Acid”.
It’s not surprising that, in the heat of the moment, someone might grab the wrong medication from an anesthesia cart or an automated dispensing cabinet (ADC). See our January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety” and other columns on ADC issues. It’s critical that high alert medications, in particular, be appropriately identifiable and appropriately segregated to prevent such inadvertent occurrences.
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Irrigation fluids have been involved in perioperative medication errors. In some cases, they may have been in unlabeled basins on the sterile field. In others, the may have been in bags intended for irrigation of certain sites (eg. bladder irrigation) and were instead connected to IV lines.
Another recent review of perioperative medication safety (Redman 2020) cited the work of Wahr et al. (Wahr 2017) that we discussed in our June 4, 2019 Patient Safety Tip of the Week “Medication Errors in the OR – Part 3”. Wahr et al. 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. We refer you to Table 4 in the Wahr review for the full list of the 35 recommendations. Redman highlighted several of these:
Redman stresses the importance of proper labeling. She cites an interesting simulation study done by Estock and colleagues (Estock 2018). In the latter study, anesthesia trainee participants were randomly assigned to either redesigned labels or the current label condition. In the simulation, the surgeon asked the participant to administer hetastarch to the simulated patient because of hemodynamic instability. The fluid drawer of the anesthesia cart contained three 500-ml intravenous bags of hetastarch and one 500-ml intravenous bag of lidocaine. The percentage of participants who correctly selected hetastarch from the cart was significantly higher for the redesigned labels than the current labels (63% versus 40%; odds ratio, 2.6). They concluded that using opaque, white 2-sided medication labels on IV bags with white text on a dark background was effective.
Monitoring is one of the most important aspects of medication safety in any venue. Patients in the OR and PACU often have monitoring that is as good or better than that done on a typical ICU patient. But monitoring is complicated by the myriad of things that can happen in the OR. For example, the occurrence of tachycardia in a patient in the OR could be a sign of an allergic medication reaction or other adverse medication effect. But it could also be due to blood loss, arousal from anesthesia, or rare conditions like malignant hyperthermia, latex allergy or LAST (local anesthetic systemic toxicity) as discussed below. Moreover, the person charged with doing most of the monitoring – the anesthetist – is often multitasking and may be distracted from key changes in monitored parameters.
Workarounds may lead to medication accidents as well. For example, an anesthetist might find it a timesaver to draw up medications from multiple vials in one setting. But that can lead to mislabeling of the syringes. Proper technique would be to draw up the medication from one vial and label that syringe before going on to the next. Workarounds should always make you look for a root cause. A root cause in this example would be lack of prefilled syringes.
We mentioned that one problem commonly encountered is that certain supplies or medications may not be readily available in the OR, leading to harried attempts to procure that medication. But the opposite problem can also occur. That is, the inappropriate presence of an unnecessary medication can lead to accidental use of that medication. Our columns on the “ophthalmology blue dye accidents” (see our columns from May 20, 2014 “Ophthalmology: Blue Dye Mixup” and September 2014 “Another Blue Dye Eye Mixup”) discussed cases where methylene blue dye was erroneously used in eye surgery instead of trypan blue. There is actually little reason to keep methylene blue in most OR setups since it is used only in a few select instances. Similarly, the tranexamic acid incidents (see our July 9, 2019 Patient Safety Tip of the Week “Spinal Injection of Tranexamic Acid”) might have been avoided because tranexamic acid is only used for a few procedures, raising the question why it would even be included in most OR setups.
LAST (local anesthetic systemic toxicity) is a syndrome that has only relatively recently gained increased recognition, which may be life-threatening (Weinberg 2010, Weinberg 2020, El-Boghdadly 2018). CNS manifestations are most common, with seizures being the most common manifestation. However, early manifestations have been quite diverse. Perioral paresthesia, confusion, audio–visual disturbances, dysgeusia, agitation, or reduced level of consciousness, and cardiovascular manifestations may include dysrhythmias, conduction deficits, hypotension, and eventually cardiac arrest. Note that the cardiovascular manifestations often occur while the patient is under general anesthesia or heavy sedation where CNS toxicity is difficult to ascertain. We refer you to the articles above for discussion of treatment, which focuses on airway management, seizure suppression, circulatory support, and the role of infusion of lipid emulsion.
Finally, though it’s not technically “medication” safety, latex allergy is a safety issue in the OR and perioperative setting that certainly comes into the differential diagnosis of medication-related issues. In our July 6, 2020 Patient Safety Tip of the Week “Book Reviews: Pronovost and Gawande” we described an excerpt from Peter Pronovost’s book “Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out” in which he describes a harrowing experience where he, as the anesthesiologist, correctly suspected a deteriorating patient had a potentially life-threatening latex allergy during surgery. He implored the surgeon in every way possible to change his gloves to non-latex ones and the surgeon refused until Pronovost put out a page to the hospital administration!
In our August 16, 2011 Patient Safety Tip of the Week “Crisis Checklists for the OR” we discussed an article by Ziewacz and colleagues (Ziewacz 2011) about having ready access to checklists for managing less common crises in the OR, such as malignant hyperthermia. We’d suggest you consider adding checklists for LAST and latex allergies to your list of crisis checklists for the OR.
We hope you’ll go back to our series of medication errors in the OR (March 24, 2009 “Medication Errors in the OR”, November 3, 2015 “Medication Errors in the OR - Part 2” and June 4, 2019 “Medication Errors in the OR – Part 3”) which had very good recommendations from ISMP (Institute for Safe Medication Practices) (ISMP 2015), PPSA (Pennsylvania Patient Safety Authority) (Cierniak 2018), AORN (Association of periOperative Registered Nurses) (Novak 2015, Litman 2018, Sones 2019, Boytim 2018), and APSF (Anesthesia Patient Safety Foundation) (APSF 2012), among others.
And it goes without saying that every attempt should be made to extend our medication safety tools to the OR. That includes integration of the OR information system with the facility-wide EMR and CPOE, use of barcoding for medication verification, use of standardized doses and pre-filled syringes, use of smart pumps, having a clinical pharmacist as part of the team, and others.
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”
June 4, 2019 “Medication Errors in the OR – Part 3”
July 9, 2019 “Spinal Injection of Tranexamic Acid”
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
Spruce L. Back to Basics: Medication Safety. AORN Journal 2020; 111(1): 103-112
https://aornjournal.onlinelibrary.wiley.com/doi/full/10.1002/aorn.12891
Patel S. Erroneous neuraxial administration of neuromuscular blocking drugs, European Journal of Anaesthesiology 2020; Published Ahead of Print May 05, 2020
Redman DD, Perioperative Medication Safety: A Continuing Challenge. AORN Journal 2020; 111(1): 116-120
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12911
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
Estock JL, Murray AW, Mizah MT, et al. Label design affects medication safety in an operating room crisis: a controlled simulation study. J Patient Saf. 2018;14(2): 101-106
Weinberg GL. Treatment of local anesthetic systemic toxicity (LAST). Reg Anesth Pain Med 2010; 35: 188-193
https://www.mcgill.ca/anesthesia/files/anesthesia/wk_4b_last_2010.pdf
Weinberg G, Rupnik B, Aggarwal N, et al. Local Anesthetic Systemic Toxicity (LAST) Revisited: A Paradigm in Evolution. APSF (Anesthesia Patient Safety Foundation) Newsletter 2020; 35(1): 1, 5-7
El-Boghdadly K, Pawa A, Chin, KJ. Local anesthetic systemic toxicity: current perspectives. Local and Regional Anesthesia 2018; 11: 35-44.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6087022/pdf/lra-11-035.pdf
Ziewacz JE, Arriaga AF, Bader AM, Berry WR, et al. Crisis Checklists for the Operating Room: Development and Pilot Testing. J Am Coll Surg 2011; 213(2): 212-219
http://www.journalacs.org/article/S1072-7515%2811%2900343-7/abstract
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
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
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
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
APSF (Anesthesia Patient Safety Foundation). Medication Safety in the Operating Room: Time for a New Paradigm. January 2012
http://apsf.org/resources/med-safety/
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June 16, 2020
Tracking Technologies
The COVID-19 pandemic has certainly changed the way we do things in healthcare as well as in society as a whole. Some changes have been very welcome. For example, telehealth has taken off and hopefully CMS (Medicare and Medicaid) and other payers will recognize the benefits of telehealth and make changes permanent. But other technologies have also found a niche in the COVID-19 era. We are talking about what we’ll refer to as “tracking technologies”. These include GPS, Bluetooth, RFID, barcoding, and probably other technologies.
Long-term care and senior living facilities have borne the brunt of the COVID-19 pandemic, both because their residents typically have the underlying diseases that predispose them to mortality from COVID-19 but also because they live in relatively confined quarters where spread of this readily contagious virus is possible. It has become very clear that to prevent spread of COVID-19 in such facilities we need to readily identify individuals infected with the coronavirus (both staff and residents) and be able to trace all the contacts they have had.
One such senior living facility recently demonstrated how use of tracking technology could be used to produce a list of such contacts in an unbelievably short time frame (Dave 2020). Because the 35 workers and 49 residents at that Amarillo Texas senior living facility wear high-tech wristbands, the facility was able to identify within 5 minutes all residents and staff who had contact with a staff member suspected of having COVID-19. Fortunately, that staff member tested negative for COVID-19, but lesson is nevertheless striking. Had they not had that system in place, extensive time-consuming interviewing would have been necessary to identify contacts.
The bracelets at that facility were not just intended to track residents and staff. They also function as a call button to summon staff, a digital room key, and a health and activity tracker. The technology also helps tell if a resident or patient has gotten out of bed, has missed meals, has had problems sleeping, and others. It helps detect patient falls and serves as a call button and two-way radio. It can even be used as a key to open doors. It also does not have to be taken off to recharge (it uses swappable batteries). The technology apparently uses RFID technology and also utilizes AI (artificial intelligence) and machine learning to identify patterns of activity.
The technology is also now being marketed for seniors living at home. It can identify changes in patterns that may point to medical issues. For example, it might identify a slowing of ambulation, more time spent in the bathroom, or more time spent in the bedroom, all of which should lead to a medical evaluation.
Think about tracking technologies in our everyday life. Almost all of us use GPS technology on a regular basis. We use it to help us navigate from one location to another. We use it when we are taking hikes through the forest or kayaking/boating in unfamiliar waterways. We can track our dogs using GPS transmitters on their collars. GPS technologies have now also been used for tracking things inside buildings, like museums or big stores. Other technologies (Bluetooth, RFID, etc.) are also available for tracking in more restricted areas. You can use some of these in museums, other big buildings, or shopping malls. We use them to track personal items. I can press a button on my smartphone to find my keys or vice versa. Grocery stores use tracking to determine inventory levels, so they know when to order more of a certain item.
Your smartphone can probably show you a map of all the places you’ve recently travelled. Such maps come from information obtained via GPS or via pinging off cellphone towers. Even if you didn’t know your phone could show you that information, your mobile phone carrier is probably collecting all that data. Other countries, which have less restrictive laws and regulations on personal privacy, have used smartphone data to help with contact tracing in the COVID-19 pandemic and this has been credited as one of the reasons they may have been more successful at stemming the spread of COVID-19.
The ability to track people or things provides tremendous opportunities in healthcare.
A hospital in Seoul, South Korea developed an infectious management solution using a Bluetooth-connected smart band to track patients moving around its premises in real time (Sae-jin 2020). The hospital said that it would further upgrade its solution to use it for analyzing routes of COVID-19 patients. To track smart bands worn by patients, the hospital set up a seamless wireless network and infrastructure for real-time location systems. And it could be used for tracking transmissible diseases other than COVID-19. For example, the hospital simulated its new solution by successfully tracking a patient infected with scabies, wearing a smart band, and identifying those who came in contact with the tracked patient.
One of the earliest uses of tracking technologies was to identify wandering patients with dementia or delirium, or detecting elopement in patients on behavioral health units. The technology can also be used in prevention of infant abductions on neonatal and labor and delivery units.
You often need to know when a patient has gotten out of his/her bed in the hospital. They may have dementia or delirium and be prone to wandering. Or leaving the bed may indicate the patient needs to use the bathroom and that assistance may be needed. Bed alarms always sounded like a great idea in hospitals. The original ones were tied to pressure transducers placed in patients’ beds. When a patient got out of bed, the transducer would trigger an alarm. But the original designs required attaching the alarms to electrical outlets and that led to staff sometimes swapping more important lines out of those electrical outlets. Also, sometimes clever patients were able to manipulate the transducers. The newer technologies do not rely on connection to electrical outlets and actually track the motion and movement of the patient.
Tracking technologies may also help with intrahospital transports in several ways. They could show where bottlenecks and delays occurred during such transports. And, back to the COVID-19 scenario, they could demonstrate where a patient having COVID-19 had travelled and whom he/she might have come in contact with during that transport.
And, speaking of transports, we’ve mentioned in several columns that Bluetooth technologies could be used to alert transporters about the adequacy of any oxygen supply needed during that transport (see our What's New in the Patient Safety World columns for Novemrber 2016 “Oxygen Tank Monitoring” and February 2018 “Oxygen Cylinders Back in the News”).
Bluetooth applications have also been used to facilitate navigation within hospitals. Our October 2019 What's New in the Patient Safety World column “Visual and Hearing Loss and Medical Costs” cited Johns Hopkins’ implementation of a Bluetooth way-finding app to help visually impaired patients. It can be used from home or while using public transportation. It has voice capability and helps navigate the patient through the hospital, including such things as telling them when to enter an elevator, what button to push, and what floor they are on.
And, as good as these technologies are at tracking people, they are even better at tracking things. Years ago, one of our hospitals was constantly losing wheelchairs. Seldom had any of them actually been stolen or otherwise left the premises. They were simply left in various locations rather than being returned to a central location. The fix was easy – installation of an RFID tracking system that told us exactly where each wheelchair was located. In fact, the led to the idea (novel at that time) that maybe a central location for wheelchairs was counterproductive! Often a wheelchair was actually in a location much closer to where it was needed. The RFID system allowed us to find the closest available wheelchair.
We’ve discussed use of these tracking technologies in multiple columns on preventing retained surgical items, particularly sponges. The root causes of retained surgical items (RSI’s) are manifold and complex and not all studies have demonstrated that tracking technologies actually reduce the incidence of RSI’s (Gunnar 2020).
Perhaps the greatest use of RFID tracking technologies in healthcare has been tracking instruments. Think of all the times you’ve been in the OR and either noted an instrument missing from the instrument tray or simply identified the need for an instrument not ordinarily included in the instrument tray for that procedure. How long did it take for you to find the instrument you needed? Probably too long. Having an RFID tracking system in place can tell you exactly where the needed instrument is located and save you substantial time. Moreover, such a system can help you avoid losing instruments. If you assign an instrument to a tray, you should be able to use RFID to check that all instruments have been returned with that tray for processing on completion of the procedure. RFID technology tracking also plays a key role in inventory management.
RFID technology has also been incorporated into medication tray management. Manual restocking of medication trays, such as those in the OR or those in resuscitation carts, is time-consuming and prone to human error. For example, an expired, used, or incorrect medication might be left in a tray. North York General Hospital in Toronto, Ontario implemented an RFID-based system to address those issues (Rolko 2015). The new system had a significant impact on both the accuracy of and time required for preparation of products stocked and the management of expired products. They estimated almost 1700 tray errors were avoided annually with the new system. The automated system also saved staff time. The study showed that an average of 4.4 minutes was saved for each tray processed.
Our April 2012 What's New in the Patient Safety World column “Specimen Labeling Errors” noted a paper from the Mayo Clinic (Francis 2009) that discussed changes made after their gastrointestinal and colorectal surgery endoscopy units had experienced mislabeling or no labeling of specimens. They initiated a new specimen-labeling system that uses RFID technology, a paperless requisition process, and confirmation of the correct site and correct patient by 2 healthcare providers. They were able to document a substantial decrease in errors as a result of the new processes.
Our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom” included a case in which a hand-held shower head and flexible metal hose were used by a patient to commit suicide. That equipment was intended to be compatible with the Americans with Disabilities Act (ADA). But this patient had no disabilities that would have merited use of that special shower apparatus and it should have been removed from that bathroom after use by someone who may have needed it. It was only intended for use under the supervision of facility staff and, when not in use, was supposed to be removed and stored in a secure location. After the incident, the hospital implemented a a sign in/out log for that shower head/hose, but it still requires someone to remember to return the shower head/hose promptly to its secure site. We suggested that, in this day and age where RFID and Bluetooth technologies are readily available, one could envision sending timed alerts to prompt removal of that item from patient bathrooms.
Time-motion studies using tracking technologies may identify bottlenecks and delays in many of your processes and help improve efficiencies in any organization. These technologies can be used to do time management studies and improve staff workflow. We recall one example tracking nurses doing rounds. It found that the nurses repeatedly had to go back to a supply room at the end of the hall. That finding ultimately led to locating certain critical supplies in several other locations that were more convenient for the nurses, saving considerable time.
In our April 29, 2014 Patient Safety Tip of the Week “More on the Unintended Consequences of Contact Isolation” we highlighted a time-motion study using location tracking via RFID chips embedded in hospital ID badges to compare the amount of time interns spent with patients in contact isolation vs those not in contact isolation (Dashiell-Earp 2014). They found that interns, on average, spent 5.2 minutes per day with their patients in contact isolation vs. 6.9 minutes in those not in isolation (p <0.001). All were surprised by how little time interns spend in direct contact with any patients, but the study confirmed that patients in isolation get less contact with their healthcare professionals.
RFID technology has also been utilized in assessing staff hand washing compliance. Our November 18, 2014 Patient Safety Tip of the Week “Handwashing Fades at End of Shift ?Smartwatch to the Rescue” highlighted a study that monitored handwashing by using RFID technology and showed that compliance with handwashing also fades late in the day or toward the end of a shift (Dai 2014).
Another study at one of our own hospitals tracked patients attending hospital outpatient clinics to improve patient flow. It confirmed some long patient stays for relatively brief visits with their physician. But the long stays were not just due to long waits in the waiting rooms. The study found the patients often had to first go to an outpatient registration area, where there might be long lines, then to the clinic waiting room, then to the lab or radiology area, where they often had to undergo yet another registration. That study led to changes in the whole system such that registration was done right in the clinic waiting room, cutting the average patient stay by more than 50%.
In an older case study from the American Hospital Association, Christiana Hospital implemented an infrared-based system to track patients in the emergency department (AHA 2009). They chose automatic patient and asset tracking software system in conjunction with an infrared sensory network and locating hardware. Infrared badges for patients, staff, and assets and in-room sensors “passively” collect real-time locations and this system interfaced with the hospital’s information management system. This allowed 100 percent of patients being immediately located at any given time. Average length of stay (LOS) decreased by 45 minutes for patients treated and released, and average LOS decreased by 35 minutes for admitted patients. In addition, average LOS for low acuity patients reduced from more than 2 hours to less than 60 minutes. There was also a reduction in low acuity patients leaving without treatment and a significant improvement in patient satisfaction.
Some have mentioned tracking technologies as part of bed management systems. Theoretically, such a system could tell when a patient no longer needed a room (the bracelet sensor is now off) and when housekeeping staff have finished in a room. Current verbal systems are often inefficient because staff responsible for declaring a bed is ready may be diverted to other activities, resulting in delays. However, our personal feeling is that bed allocation is more complex and might not be suitable for simple tracking technologies. For example, there may specific requirements for beds (eg. gender issues, need for isolation or special ventilation, etc.).
And don’t forget good old barcoding technology! You see it every day in your grocery store. That is how they keep track of stock so they know what and when they should reorder it. That has also been a staple for inventory management in many hospitals for years. It might also help with your facility’s billing since you should be able to link an item’s barcode to a specific patient. A recent article on such systems (Kraft 2020) noted the following benefits of such systems:
CCTV (closed circuit television) and motion-sensitive cameras are yet other tracking technologies. All too often CCTV films are reviewed after the fact (for example, after a patient has already wandered off the premises) unless someone is continuously visualizing the camera feeds. But some motion-sensitive surveillance cameras can distinguish humans from other causes of motion and send an alert to a smart phone or other notification device. They can be placed, for example, in a stairwell that a patient might utilize to abscond from a secure unit.
So, are tracking technologies immune to error? Of course not. We’ve seen patients with dementia figure out how to remove their tracking bracelets. And a behavioral health patient trying to elope would likely know how to remove his or her bracelet before leaving the premises. Sensors may occasionally be rendered unresponsive due to physical trauma. RFID signals can be disrupted if the tag is attached to a metal object or placed underwater (Nichols 2020). You’ve all seen circumstances in your everyday life where your GPS or Bluetooth signals get blocked. Certain environmental issues might also temporarily disable some of the array of tracking sensors needed, creating dead zones where a patient or item might be lost to contact. And, of course, the same types of errors we see in other patient misidentification cases can also occur with tracking technologies. Just as putting a barcoding ID bracelet on the wrong patient leads to errors, the same could happen if you put a tracking bracelet on the wrong patient.
But, overall, the potential capabilities of these tracking technologies are incredible. There are probably more uses that we have not covered. We’d like to hear about them. Let us know if you have other examples of their use in healthcare.
Update (July 4, 2020): Since this column, Rensselaer Polytechnic Institute announced it has developed a new system of infrared sensors that maintains privacy while keeping patients safe (RPI 2020). A set of sensors uses infrared light to measure distances between sensors and objects in order to identify where someone may be in a room. It measures distance, but it can tell if a person is standing, sitting, or lying down on the floor. It can tell the difference between where people are standing and how they are interacting with other people. RPI notes that such measurements could alert a caregiver that someone has fallen, document the last time someone checked on their loved one, or even help detect cognitive decline over time. RPI notes there is nothing new about use of infrared. What’s new is the development of a very inexpensive sensor that has data analytics built right into it, allowing the sensors to collect data, process it, and communicate with each other in order to track movement within a room. It’s that affordability that will be essential for widespread implementation. The press release says “It’s sort of like radar, only it uses light.” The press release has a short video that illustrates potential uses. Because it does not capture images, it protects privacy yet yields valuable information about potential health problems.
Reference:
RPI (Rensselaer Polytechnic Institute). New system of infrared sensors maintains privacy while keeping patients safe. Medical Xpress 2020; June 23, 2020
https://medicalxpress.com/news/2020-06-infrared-sensors-privacy-patients-safe.html
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Dave P. Elderly Home Turns to Wearables for Contact Tracing, Sidestepping Apple-Google Limits. Medscape Medical News 2020; May 20, 2020
Sae-jin PS. Korean hospital develops location information-based solution to track patient movement. Aju Business Daily 2020; April 21, 2020
http://www.ajudaily.com/view/20200421104059328
Gunnar W, Soncrant C, Lynn MM, et al. The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration, Journal of Patient Safety 2020; Publish Ahead of Print March 24, 2020
Rolko E, Chan T. Implementation of Radio Frequency Identification for Medication Tray Management. The Canadian Journal of Hospital Pharmacy 2015; 68(5): 412-416
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4605466/
Francis DL, Prabhakar S, Sanderson SO. A Quality Initiative to Decrease Pathology Specimen–Labeling Errors Using Radiofrequency Identification in a High-Volume Endoscopy Center. Am J Gastroenterol 2009; 104: 972–975
https://journals.lww.com/ajg/Abstract/2009/04000/A_Quality_Initiative_to_Decrease_Pathology.27.aspx
Dashiell-Earp CN, Bell DS, Ang AO, Uslan DZ. Do Physicians Spend Less Time With Patients in Contact Isolation? A Time-Motion Study of Internal Medicine Interns. JAMA Intern Med 2014; Published online March 31, 2014
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1847570
Dai H, Milkman KL, Hofmann DA, Staats BR. The impact of time at work and time off from work on rule compliance: The case of hand hygiene in health care. Journal of Applied Psychology 2015; 100(3): 846-862
https://psycnet.apa.org/fulltext/2014-45053-001.html
AHA (American Hospital Association), Automated Patient Tracking in the ED. (Christiana Hospital). Hospitals in Pursuit of Excellence. Case Studies. September 24, 2009
https://www.aha.org/system/files/hpoe/Case_Studies/ChristianaHospital_Patient_Tracking_ED.pdf
Kraft J. Do You Know Where Your Instruments Are? Tracking software provides the data needed to improve clinical efficiencies and patient care. Outpatient Surgery 2020; XXI(4): April 2020
Nichols MR. How Does RFID Technology Reduce Medical Errors? VAR Insights 2020; May 7, 2020
https://www.varinsights.com/doc/how-does-rfid-technology-reduce-medical-errors-0001
Print “Tracking Technologies”
June 23, 2020
Telemetry Incidents
In our numerous columns on alarm fatigue and alarm management, we’ve emphasized that one of the interventions strongly recommended to reduce alarm fatigue is to eliminate unnecessary telemetry monitoring. Far too many patients are placed on telemetry monitoring without appropriate indications or are unnecessarily continued on telemetry monitoring after a legitimate need is no longer present. See our What's New in the Patient Safety World columns for October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry” and December 2018 “Cost Savings from Eliminating Unnecessary Telemetry Monitoring” and our April 16, 2019 Patient Safety Tip of the Week “AACN Practice Alert on Alarm Management”.
But what about when use of telemetry monitoring is appropriate? What can go wrong? Actually, lots can go wrong and the result is often devastating.
One of our earliest Patient Safety Tips of the Week “Unintended Consequences of Technological Solutions” described one such event. A hospital purchased such a remote telemetry system in which the transmitter could be placed on a patient on one floor of a hospital and the receiver/monitor was in the CCU as part of a bank of telemetry screens that were continuously viewed by a nurse assigned to that duty. One day, right around nursing change of shift, two patients were admitted to the remote floor and telemetry was ordered on both. A nurse took two transmitters with him and hooked the patients up, then called the CCU monitoring nurse to tell her about the two patients just hooked up. About an hour later the CCU monitoring nurse called the remote floor because one of the patients was in ventricular fibrillation. A code was called and the floor staff and code team ran to the patient’s room, only to find him sitting up in bed, watching TV and eating a meal. Only after several minutes of fiddling with his EKG leads and talking to the nurse in the CCU did anyone realize that the patient several rooms down the hall was really the one in ventricular fibrillation. The transmitters obviously had been transposed! This is a variation of the “two in a box” phenomenon we talked about in the April 23, 2007 Tip of the Week “Predictable Errors”. And, of course, the system was poorly designed in that it allowed the first nurse to take out two remote telemetry transmitters at the same time.
In our July 2011 “What's New in the Patient Safety World” column we noted that the ECRI PSO issued a Patient Safety E-lert on the very same issue (ECRI PSO 2011). They did not provide details of the cases in their database but did discuss contributing factors identified and made several good recommendations. They noted lack of good policies and procedures and lack of orientation and training plus communications failures as important contributory factors. They specifically noted things like change of shift, inexperienced staff, lack of familiarity with procedure, and distractions. They also note technological issues and workflow issues.
They recommend patient identification be verified each time a patient is hooked up to telemetry (and that means verification at both the patient’s end and the remote monitoring site). They stress that the telemetry receivers should incorporate a display with the patient identifiers to reconcile the telemetry transceiver with the correct patient (and to be especially cautious about patients with similar names). That patient identification needs to be done independently at the two sites to avoid confirmation bias. To their recommendations we would reiterate that your system should also use the constraint function of preventing anyone from taking out two transceivers simultaneously. Allowing more than one at a time to be taken simply increases the probability of such transposition.
Incidents related to telemetry often occur during intrahospital transports. Many of our columns highlighting the dangers of the Radiology Suite stress that the dangers often have no relation to the radiology procedure. Our May 22, 2018 Patient Safety Tip of the Week “Hazardous Intrahospital Transport” discussed a report from the California Department of Public Health (CDPH 2018) that illustrates the problem. A patient had been admitted after being found on the floor and noted to be in atrial fibrillation. He was placed on telemetry and had orders for serial EKG’s and cardiac enzymes. It is not clear from the report whether the atrial fibrillation was persistent but subsequent EKG’s apparently showed PVC’s with trigeminy. A nurse notified his physician about the trigeminy and he was begun on oxygen 2 L/min. He was scheduled for an MRI scan of the head (reason not provided in report). The nurse apparently contacted the physician, who ok’d sending the patient for the MRI, though it did not appear the physician realized the patient would be transported without telemetry monitoring. No RN accompanied the patient to the MRI suite and he was not monitored in transit nor connected to telemetry on arrival at the MRI suite. The MRI technician did call the telemetry unit and asked a nurse whether the patient needed monitoring and the answer was “no”. The patient was initially advanced into the MRI machine but was pulled out when he complained of shortness of breath. He sat up and was placed on high flow oxygen again but agreed to attempt the MRI again. He then asked to be pulled from the MRI again. As the MRI tech moved the patient back to the hallway and assisted him getting back in bed, the patient had a cardiac arrest. A code was called but attempts at resuscitation were unsuccessful.
The hospital’s policy on intrahospital transports had been revised about two years earlier to enable registered nurses to utilize clinical criteria to discontinue telemetry for select patients for transport to and during a test. The hospital, in its POC (plan of correction), again revised its policy and protocol for transport of monitored patients. It would require a physician’s order stating that the patient could be transported without monitoring. If telemetry or other form of monitoring is to be continued, an RN must accompany the patient to the receiving area. The POC also included appropriate dissemination of the revised policy, inservice training, and an audit of subsequent transports of telemetry patients. Though the hospital POC mentions the hospital uses patient safety tools like the Lean Daily Management Huddle on each nursing unit and multidisciplinary hospital Safety Huddles, there is no mention whether the hospital utilizes checklists like the “Ticket to Ride”. We have highlighted “Ticket to Ride” in multiple columns (see list below). It was originally started to ensure that patients being transported had adequate oxygen supplies, since some studies showed that over half of patients transported to sites like the radiology suite ran out of oxygen. But the “Ticket to Ride” checklist is a good way to remind everyone to address what should be done about remote monitoring when patients are transported.
Our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” highlighted another issue related to remote monitoring: battery drainage. A patient was being monitored by remote telemetry (CDPH 2014). The battery charge on the 9-volt battery on the remote unit was running low. The audible alarms for low battery status had been turned off and the only ones working were the visual ones. A low battery warning appeared as a yellow alarm on the screen. It later turned red but once the battery is dead no tracing at all appears on the remote monitor screen. The nurse who was manning the remote monitoring station (because no monitor tech was available) had multiple other distractions and did not see the yellow or red low battery alerts. The patient has a fatal event not picked up by monitoring.
Our February 23, 2010 Patient Safety Tip of the Week “Alarm Issues in the News Again” reminds us not to forget that monitoring and alarm systems consist of much more than pieces of medical equipment. The Pennsylvania Patient Safety Authority’s “Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis” analyzed data on alarm-related incidents from the Pennsylvania Patient Safety Reporting System and identified 29 steps involved in the telemetry monitoring process (see our April 1, 2008 Patient Safety Tip of the Week “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”). They provide excellent recommendations regarding patient identification, optimal display location, ensuring the power source of the telemetry receivers, protocols for when monitoring is temporarily suspended or on standby (eg. during transport or while electrodes are being manipulated), protocols for alarm volume levels, electrode placements and inspection and maintenance, making alarm parameters appropriate to both the individual patient and the setting, and protocols for responding to all alarms (whether low- or high-priority alarms) including establishment of a tiered backup response system. They also point out a very important question easily overlooked in a FMEA “Is telemetry monitoring indicated in this patient at all?”.
A more recent report from the Pennsylvania Patient Safety Authority (Kukielka 2019) analyzed 558 events reported to the Patient Safety Reporting System (PA-PSRS) over a 5-year period. These events specifically involving interruptions or failures associated with telemetry monitoring equipment or with the healthcare providers responsible for setting up and maintaining proper functioning of that equipment.
Almost half (47.1%) the events were attributed to user errors. But other errors included:
Common scenarios were not keeping patients on telemetry when they left the floor for testing or forgetting to reconnect telemetry when they returned, poor handoffs at transfers, unsuccessful attempts by the monitoring nurse to reach the nursing staff on the floor when a significant arrhythmia occurred, dead batteries, and the classic error: alarm disabled or volume reduced to inaudible levels. And, yes, just as in our earliest case, the problem of two or more patient having their telemetry monitoring equipment switched happened again. In one such case, they provided details. Two patients in the same room were being monitored via telemetry. At some point their equipment was disconnected and mixed up before being reconnected. One of the patients then developed a rapid heart rate and an intravenous medication was ordered. Fortunately, as they were about to administer that medication, they identified the mix up and avoided what could have been a serious outcome.
The authors point out that harm associated with telemetry monitoring is rare but potentially catastrophic, with death being the most frequent outcome among serious events. Communication breakdowns, battery issues, and improper alarm settings rounded out their top 4 take home points.
Our own take home points:
See also our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” and our many columns on alarm-related issues listed below.
Some of our prior columns on the hazards associated with telemetry:
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
Some of our prior columns on the “Ticket to Ride” concept:
References:
(Note: some of the links to the publications prior to 2015 listed below may no longer be valid)
ECRI PSO. Patient Safety E-Alerts. Patient Identification Prevents Life-Threatening Events. Did you Double-Check the Cardiac Monitor? May 2011
https://www.ecri.org/PatientSafetyOrganization/Documents/E-lert_Patient_Identification.pdf
CDPH (California Department of Public Health). Complaint CA00221802. Accessed 2/2/14
CDPH (California Department of Public Health). 2018. Intake Number CA00462998. Accessed April 21, 2018
PPSA (Pennsylvania Patient Safety Authority). Patient Safety Advisory supplement “Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis”. March 2008
Kukielka E, Gipson KR, Jones R. A Brief Analysis of Telemetry-Related Events. Patient Safety 2019; 1(2): 36-44 December 2019
https://patientsafetyj.com/index.php/patientsaf/article/view/telemetry/67
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June 30, 2020
What Happens after Hospitalization?
It’s been 7 years since Harlan Krumholz described the “Post-hospital syndrome—an acquired, transient condition of generalized risk” (Krumholz 2013). He described that recently hospitalized patients experience a period of generalized risk for a range of adverse health events and called this a post-hospital syndrome, “an acquired, transient period of vulnerability”. He suggested that the “the risks in the critical 30-day period after discharge might derive as much from the allostatic and physiological stress that patients experience in the hospital as they do from the lingering effects of the original acute illness”. This state leaves patients vulnerable to readmission, often for conditions different from that of the index hospitalization. He went on to describe some of the likely factors contributing to this reduction of functional reserve, including metabolic derangements, disturbed sleep patterns, nutritional factors, cognitive factors, pain and other discomforts, etc. The data presented by Krumholz pertained primarily to Medicare patients, hence those age 65 and older.
We bleed them. We don’t feed them. We don’t let them sleep. We force them to stay in bed. We give them medications that cloud their attention and cognitive abilities. And our interventions draw upon their limited reserve capacities. So, should you be surprised they have new disabilities following discharge?
A new study (Dharmarajan 2020) shows that a significant percentage of older adults develop new disabilities after hospitalization and that these disabilities may persist for months. The researchers followed for at least 6 months 515 community‐living persons, mean age 82.7 years, hospitalized for acute noncritical medical illness and alive within 1 month of hospital discharge. Patients were participants in the Precipitating Events Project (PEP) who lived in the community at the beginning of the study. On entry into PEP they were not disabled and were independent in activities of daily living.
They found that disability was common 1 and 6 months after hospitalization for activities frequently involved in leaving the home to access care, including walking a quarter mile (prevalence 65% and 53%, respectively) and driving (65% and 61%). Disability was also common for activities involved in self‐managing chronic health conditions including meal preparation (53% and 41%) and taking medications (41% and 31%). New disability was common and often prolonged. For example, 43% had new disability walking a quarter mile, and 30% had new disability taking medications, with mean recovery time of 1.9 months and 1.7 months, respectively. Findings were similar for the subgroup of persons residing at home (ie, not in a nursing home) at the first monthly follow‐up interview after hospitalization.
The authors note their findings have important implications for clinical practice and
research. Because so many patients who have disability after hospitalization may have undue difficulty leaving their homes to access office-based ambulatory care, we need better ways to deliver care in the home. Their suggested potential interventions include provider house calls, home-based laboratory and radiology testing, and telehealth. They note, however, factors hampering such services include poor reimbursement rates by payers, limited workforce capacity, and regulatory restrictions limiting qualification for these options. (Note that we are hopeful that the success of telehealth during the COVID-19 crisis may lead to permanent changes in reimbursement for telehealth services.)
They also note that services should extend to nonskilled providers such as home health aides and homemakers, who can help patients self-manage their health through many means including meal preparation and medication management.
Significantly, their data show these home services may be needed for prolonged periods of time (beyond the 30-day period that has been the focus of hospitals’ readmission prevention efforts to date).
What’s most striking in the Dharmarajan study is the magnitude of the new disabilities. Perhaps the biggest message is that the time horizon for discharge planning should focus on more than just the next month. Life significantly changes for many patients after discharge following serious illness. Failure to recognize their new disabilities and provide resources necessary to deal with them will likely lead to avoidable future use of even more healthcare resources. For example, our July 2020 What's New in the Patient Safety World column “Not Following Medication Changes after Hospitalization?” discusses some serious consequences of failure to heed medication changes after a hospitalization.
We are often too focused on what happens in the hospital. We don’t focus enough on what happens after hospitalization. 46.6% of patients in the Dharmarajan study were living alone. We need to put systems in place to help those patients navigate a complicated healthcare system at a time when their disabilities make such navigation difficult. Managed care organizations have long recognized those vulnerabilities and assigned case managers, clinical pharmacists, home care workers, community healthcare advocates, meals on wheels, etc. to such patients and made available transportation to facilitate access to pharmacy and other healthcare resources. (The patients in the Dharmarajan study were said to be from “a large health plan”, possibly a Medicare Advantage plan, but details of the resources made available were not included in the article.). It’s clear that the expenses for some of those services may not be recognized as “traditional medical expenses” but they can obviously go a long way to reduce overall “medical” expenses.
Some of our prior columns on frailty:
References:
Krumholz HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med 2013; 368(2): 100-102
https://www.nejm.org/doi/full/10.1056/NEJMp1212324
Dharmarajan K, Han L, Gahbauer EA, Leo‐Summers LS, Gill TM. Disability and Recovery After Hospitalization for Medical Illness Among Community‐Living Older Persons: A Prospective Cohort Study. J Am Geriatr Soc 2020; 68: 486-495 Published online February 21, 2020
https://onlinelibrary.wiley.com/doi/10.1111/jgs.16350
Print “What Happens after Hospitalization?”
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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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Grantham, NH 03753
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