Healthcare Consulting Services
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax
April 5, 2022
Follow-up on Incidental Findings
Our April 13, 2021 Patient Safety Tip of the Week “Incidental Findings – What’s Your Strategy?” and our February 2022 What's New in the Patient Safety World column “Managing Incidental Findings” discussed several strategies used to promote adequate follow=up of incidental findings on imaging studies. But do they work? A recent study suggests that they are successful.
Bagga and colleagues (Bagga 2022) did a before and after comparison of an intervention to promote completion of recommended follow-up for incidental lung nodules. The intervention was use of structured recommendations for follow-up on imaging reports plus implementation of an electronic tracking system. They identified 255 patients before and 1,046 patients after structured recommendations or tracking.
40% of patients pre-intervention had no follow-up vs. 29.5% after the intervention. Of those who did get follow-up, 75.0% were followed up on time after the intervention, compared to 56.6% before the intervention. Looking at multiple factors, they found that younger age, White race, outpatient setting, and larger nodule size were significantly associated with appropriate follow-up completion, but use of structured recommendations was not an independent predictor. Similar results applied for loss to follow-up. In the post-intervention cohort, older age, history of smoking, categories with >6 month follow-up recommendations, and inpatient or ED setting were statistically more likely to have loss to follow-up.
Perhaps most importantly, they found that emergency department patients and inpatients are at high risk of missed or delayed follow-up despite structured recommendations. That comes as no surprise to us. Our numerous columns on “tests pending at discharge” apply equally to patients discharged from the ED or the inpatient service. Fragmentation of care is a problem there. Often, the imaging study is obtained and reviewed by the clinicians caring for the patient. But the official report may not arrive until after the patient has been discharged. The radiologist may attempt to reach the “ordering” physician, but that physician may no longer be available (hospitalists and ER physicians may have schedules that only place them in a hospital periodically) and is not likely the physician who would order any follow-up studies. And, in several columns, we’ve noted the difficulties often encountered in identifying in the EHR the primary care physician or other physician who will be following the patient after discharge.
So, three of our recommendations are important:
Bagga et al. did note that, during the period of initiating structured recommendations at their institution, the ED began a coordinator service for communicating follow-up needs to patients for specific recommendations in imaging reports.
The authors conclude that appropriate follow-up completion and loss to follow-up improved when the structured recommendation system was in place, but further efforts to reach patients for missed follow-up may be best focused upon inpatient and ED discharge processes and care coordination.
Lacson et al. (Lacson 2018) reported on a health IT intervention that included discharge modules for both ED and inpatient settings, which allowed access to critical findings of pulmonary nodules and recommendations for follow-up management. These online modules enable physicians caring for patients in the ambulatory setting to access these recommendations after patients are discharged. The module for the ED was developed to replace a paper-based discharge instruction form. The implementation of a discharge module resulted in improved follow-up of patients with pulmonary nodules within 1 year after discharge (OR = 1.64). The ED implementation resulted in better follow-up compared to the inpatient module (OR = 2.24). Twenty-seven percent of patients with pulmonary nodules received follow-up management, which, although significantly improved from the 18% baseline, remains low.
In another study by Lacson et al. (Lacson 2022) on follow-up of patients with incidental pulmonary nodules, the only significant factor associated with follow-up completion was care setting. Imaging ordered in the ED had decreased odds of follow-up (odds ratio: 0.15). Those authors note that incidental findings in ED imaging are often not communicated to the responsible provider and, thus, stress the need for improved handoff processes. They suggest that specific interventions, like a closed-loop communication tool to establish a follow-up care plan, may be useful to further increase follow-up completion, especially in managing patients who span multiple care settings.
In our mind, structured imaging reports that include recommendations regarding follow-up for incidental findings are important. But, more importantly, having systems in place to ensure that the clinician most likely to be responsible for that follow-up is, in fact, made aware of the finding is critical. And having tracking systems in place to determine whether such follow-up was achieved is also important.
And, of course, the clinician with ultimate responsibility for follow-up must have in place his/her own “tickler” system to remind him/her to order recommended follow-up imaging after the number of months in any recommendation. That’s especially important since Bagga et al. noted higher failure to follow-up when the recommended time frame for action was 6 months or longer. Letting the patient know about the recommendation may also help alert the clinician that the follow-up is due. The patient also needs to be aware of the need to follow-up in the event he/she moves or switches to another clinician.
Again, we cannot overemphasize that “closing the loop” is the most important factor in preventing patients from “falling through the cracks”.
See also our other columns on communicating significant results:
References:
Bagga B, Fansiwala K, Thomas S, et al. Outcomes of Incidental Lung Nodules With Structured Recommendations and Electronic Tracking. JACR 2022; 19(3); 407-414
https://www.jacr.org/article/S1546-1440(21)00919-4/fulltext
Lacson R, Desai S, Landman A, et al. Impact of a health information technology intervention on the follow-up management of pulmonary nodules. J Digit Imaging 2018; 31: 19-25
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5788828/
Lacson R, Licaros A, Cochon L, et al. Factors Associated With Follow-up Testing Completion in Patients With Incidental Pulmonary Nodules Assessed to Require Follow-up. JACR 2022; 19(3); 433-436
https://www.jacr.org/article/S1546-1440(22)00011-4/fulltext
Print “Follow-up on Incidental Findings”
April 12, 2022
A Healthcare Worker’s Worst Fear
As healthcare workers, our worst fear is that we might make a mistake that causes harm or death to one of our patients. Some also fear that such a mistake will lead to loss of respect from colleagues or a malpractice suit. But few would fear that such a mistake could lead to criminal charges and time in prison.
But all that changed recently. In multiple columns we discussed the tragic incident at Vanderbilt in which a patient died after accidentally being given the neuromuscular blocking agent (NMBA) vecuronium instead of the sedating agent Versed. See our Patient Safety Tips of the Week for December 11, 2018 “Another NMBA Accident”, January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”, February 12, 2019 “From Tragedy to Travesty of Justice”, and September 7, 2021 “The Vanderbilt Tragedy Gets Uglier” for details. In late March 2022 a jury convicted RaDonda Vaught, the nurse involved in that incident, of gross neglect of an impaired adult and negligent homicide (Kelman 2022). She was acquitted of reckless homicide, a more serious charge than negligent homicide.
Vaught did make multiple serious mistakes in the incident. But there were multiple system problems that contributed to the devastating outcome. In fact, in our prior columns we identified at least 19 points where interventions or different decisions could have prevented this tragic death.
Any time we review an incident in which human error occurred, we always ask “Could another nurse/physician/pharmacist have made similar errors under these same circumstances?”. In the Vanderbilt NMBA incident, we concluded that it was quite conceivable that another nurse might have made similar errors given the same set of circumstances and contributing factors. That is, the many system issues actually put that nurse in a position where human error would leave her at the “sharp end” of the error cascade. As such, we would not have even recommended terminating the nurse. Yet she ultimately had her nursing license revoked by the Tennessee Board of Nursing and now has been convicted of these criminal offenses.
Vaught readily admitted the error(s) immediately after the incident and showed remorse at every stage. Vaught did not testify in the trial. But, according to Kaiser Health News (Kelman 2022), she previously admitted to the drug error in an interview with law enforcement officials in which she and said she "probably just killed a patient." And, during proceedings before the Tennessee Board of Nursing she testified that she allowed herself to become "complacent" and "distracted" while using the medication cabinet and did not double-check which drug she had withdrawn despite multiple opportunities. She told the nursing board "I know the reason this patient is no longer here is because of me" and, as she broke down crying, "There won't ever be a day that goes by that I don't think about what I did."
It is worthwhile reiterating details of the incident, its contributing factors, and lessons learned. We pieced together details of the case from the CMS inspection report (CMS 2018) and media reports at the time (NewChannel5 2018), (Kelman 2018a), (Kelman 2018b), (Ellison 2018).
The patient was a 75 y.o. woman with an intracranial hemorrhage, admitted to the hospital’s Neuro ICU. Two days later she was alert and oriented and stable and was now in the Neuro Stepdown Unit and waiting for a bed on the regular floor. On that day she was sent to the radiology department for a total body PET scan. The patient told staff about claustrophobia and a physician ordered Versed 2 mg intravenously for sedation for the procedure. PET scan staff requested a nurse from the Neuro ICU administer the Versed because their own nurses would not be able to perform monitoring of the patient.
That nurse from the Neuro ICU was already going to the ER to administer a swallowing study. The nurse looked in the patient’s profile on the ADC (Automated Dispensing Cabinet) for the Versed but could not find it. (The ADC was in the Neuro Intensive Care Unit, not in radiology.) Therefore, the nurse used the override function on the ADC to search for it. The nurse recalled talking to an orientee about the swallowing study while entering the first two letters “VE” into the ADC. The first medication on the list was chosen. The nurse did not recognize that the medication chosen was vecuronium, not Versed. The nurse looked at the back of the vial to see how to reconstitute the medication but did not recheck the name of the medication on the vial. The nurse grabbed a sticker from the patient’s medication file, a handful of flushes, alcohol swabs, and a blunt-tip needle. The nurse put the medication vial in a baggie and wrote on the baggie “PET scan, Versed 1-2 mg” and went to Radiology to administer the medication. The nurse found the patient waiting in the PET scan area, reconstituted the medication, and administered the medication intravenously to the patient, then left the PET scan area. In the CMS interview the nurse could not remember the exact dose administered but thought it was 1 milliliter. The nurse put the leftover medication in the baggie and gave it to another nurse. The nurse did not monitor the patient after administering the medication.
The order for Versed had been entered at 2:47 PM. It was verified by a pharmacist at 2:49 PM. It was never dispensed from the ADC. Vecuronium, however, was dispensed from the ADC at 2:59 PM, via the override function. There was never an order for vecuronium and no verification from a pharmacist.
The nurse did not document the administration of the medication. Apparently the nurse had been told that the “new system” would capture it in the MAR.
Sometime after the administration of the vecuronium the patient was found unresponsive. CPR was administered and resuscitation efforts included intubation and restoration of a heartbeat. The patient was not actually in the PET scan when she suffered the arrest. The patient was first in an “injection room” where she received injection of the radioactive tracer and then the injection of what was thought to be Versed. The patient was then moved to a “patient room” where they are expected to wait for up to an hour for the radioactive tracer to circulate. It was in this room where the patient was found by a transport attendant to be “unresponsive”. Radiology technicians were able to visualize the patient in that room (via camera) and noted she had her eyes closed but resolution was not good enough for them to detect whether she was breathing or not. It was estimated that 30 minutes had elapsed from the time the patient was put in that “patient room” and the time she was found unresponsive.
Nurses in the Neuro ICU heard the code call to Radiology and wondered whether it might be for their patient who was having a PET scan. It was their patient, and she was brought back to the Neuro ICU after the resuscitation. There a second nurse showed the baggie to the first nurse and asked “Is this the med you gave the patient?”. When the nurse answered “yes”, the second nurse said “This isn’t Versed. It’s vecuronium.”
The patient was subsequently put on comfort care after discussion with family about the neurological sequelae and died the following day.
Clearly, Vaught made the following errors:
We refer you back to our December 11, 2018 Patient Safety Tips of the Week “Another NMBA Accident” and February 12, 2019 “From Tragedy to Travesty of Justice” for discussion of all the system issues we identified as root causes or contributing factors. But, to summarize, we identified at least 19 points where interventions or different decisions could have prevented this tragic death:
It is conceivable that a different action or decision at any one of the above 19 points might have prevented this tragic accident. Yes, several of these relate directly and solely to the nurse. But the majority are enabling factors that can allow a human error to break through multiple defense systems and lead to patient harm.
ADC overrides are a central issue in this case. Vaught did override a warning on the ADC screen. But we identified two system issues regarding ADC overrides. First, hospital policy and ADC settings apparently did not require an independent double check for the override.
Second, even more importantly, the warning on the ADC screen was inadequate. The nurse may well have considered this a “STAT” order since she was told to go down to the PET suite now or they will send the patient back here without doing the scan. The hospital had been having some technical problems with medication cabinets in 2017 but they were apparently resolved prior to Vaught pulling the wrong medication from the ADC The hospital’s medication safety program director testified during the trial that, at the time of the incident, there was labeling on the pockets for paralyzing agents that gave a warning to nurses when they remove it from the drug case. "There's a pop-up message and another layer or warning that you're accessing a paralyzing agent." (Sutton 2022).
Our recommendation is that the warning for removal of an NMBA should include a “hard stop”, i.e. it should require a specific action prior to removal. A proper warning would have said something like “Verify that the patient is intubated and mechanically ventilated or that this drug is being used for an intubation procedure” and require that verification on screen.
Note that ISMP (ISMP 2019), in its own review of the issue following this case, agrees with us and recommends “Display an interactive warning (e.g., “Patient must be intubated to receive this medication”) on ADC screens that interrupts all attempts to remove a neuromuscular blocker via a patient’s profile or on override. The warning should require the user to enter or select the purpose of the medication removal (“other” should not be a choice) and verify that the patient is (or will be) manually or mechanically ventilated. This type of warning provides an opportunity to specify why the user is being interrupted and requires the user to document a response.”
We also don’t know what the unit’s “culture” was regarding overrides. The CMS inspection report (CMS 2018) does not mention whether overriding an ADC alert was an issue unique to this nurse or whether ADC overrides had become a routine part of the culture of the unit (i.e. “normalization of deviance”). How often do nurses in that unit (or elsewhere in the hospital) override warnings when removing drugs from an ADC? Hospitals need to keep logs of ADC overrides and include review of these in their quality improvement and patient safety activities.
Another issue raised by this case has to do with the number of letters needed to be entered on the ADC screen to identify a drug. In this case, entering just “VE” led to vecuronium being chosen rather than Versed. In 2019 ISMP, in its “Guidelines for the Safe Use of Automated Dispensing Cabinets”, recommended the entry of a minimum of five characters of a drug name during searches in ADC’s. (Note that ISMP’s “Guidelines for Safe Electronic Communication of Medication Information” also include that requirement for medication searches on other forms of electronic communication.) That is an improvement but, even then, there are challenges. ISMP saw reports where even entry of 5 letters was associated with errors (ISMP 2021) and summarized the circumstances in which these errors were occurring. Despite these limitations and challenges, ISMP still recommends using at least five characters when conducting drug name searches. In that 2021 article ISMP has recommendations for dealing with drug names with the same beginning characters beyond five letters and some other problematic issues.
The verdicts in this case go well beyond the travesty of justice done to RaDonda Vaught. They have implications that will be on the minds of healthcare workers everywhere. The American Nurses Association issued the following statement (ANA 2022) after the verdict in this case was reached:
“We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes.
Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action. The non-intentional acts of Individual nurses like RaDonda Vaught should not be criminalized to ensure patient safety.
The nursing profession is already extremely short-staffed, strained and facing immense pressure – an unfortunate multi-year trend that was further exacerbated by the effects of the pandemic. This ruling will have a long-lasting negative impact on the profession.
Like many nurses who have been monitoring this case closely, we were hopeful for a different outcome. It is a sad day for all of those who are involved, and the families impacted by this tragedy.”
And the American Organization of Nursing Leadership (AONL 2022) issued the following statement:
“The verdict in this tragic case will have a chilling effect on the culture of safety in health care. The Institute of Medicine’s landmark report To Err Is Human concluded that we cannot punish our way to safer medical practices. We must instead encourage nurses and physicians to report errors so we can identify strategies to make sure they don’t happen again. Criminal prosecutions for unintentional acts are the wrong approach. They discourage health caregivers from coming forward with their mistakes, and will complicate efforts to retain and recruit more people in to nursing and other health care professions that are already understaffed and strained by years of caring for patients during the pandemic.”
We, too, are concerned. We hope that this does not lead to failure to report medical errors because of fear of criminal action. There obviously was no criminal intent by RaDonda Vaught. She was straightforward in owning up to the mistakes she made and she lives with this every day. We hope that reporting and analysis of this tragic case have led to multiple improvements and lessons learned that every healthcare organization should be aware of.
We hope that RaDonda Vaught will appeal the convictions. Absent that, we hope that the judge will show leniency in sentencing. It has been a tragedy for the family of the patient who died unnecessarily. But it is also a tragedy for RaDonda Vaught and nurses and healthcare professionals everywhere.
Some of our prior columns on neuromuscular blocking agents (NMBA’s):
June 19, 2007 “Unintended Consequences of Technological Solutions”
July 31, 2007 “Dangers of Neuromuscular Blocking Agents”
November 2007 “FMEA Related to Neuromuscular Blocking Agents”
May 20, 2008 “CPOE Unintended Consequences - Are Wrong Patient Errors More Common?”
January 31, 2012 “Medication Safety in the OR”
February 7, 2012 “Another Neuromuscular Blocking Agent Incident”
October 22, 2013 “How Safe Is Your Radiology Suite?”
December 9, 2014 “More Trouble with NMBA’s”
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
February 12, 2019 “From Tragedy to Travesty of Justice”
April 2019 “ISMP on Designing Effective Warnings”
February 2021 “ISMP: 2 Alerts on NMBA’s”
September 7, 2021 “The Vanderbilt Tragedy Gets Uglier”
References:
Kelman B. Nurse Convicted of Neglect and Negligent Homicide for Fatal Drug Error. Kaiser Health News 2022; March 25, 2022
https://khn.org/news/article/radonda-vaught-nurse-drug-error-vanderbilt-guilty-verdict/
CMS (Centers for Medicare and Medicaid Services). Statement of Deficiences. Complaint #TN00045852. CMS 2018; Date of survey 11/08/2018
NewChannel5. Vandy patient dies after nurse gives lethal dose of wrong drug; threatened Medicare reimbursements. NewsChannel5 (Nashville, TN) 2018; November 29, 2019
Kelman B, Vanderbilt didn’t tell medical examiner about deadly medication error, feds say. Nashville Tennessean 2018; Published Nov. 29, 2018 | Updated Nov. 30, 2018
Kelman B, At Vanderbilt, a nurse's error killed a patient and threw Medicare into jeopardy. Nashville Tennessean 2018; Published Nov. 29, 2018
Ellison A. CMS threatens to terminate Vanderbilt's Medicare contract after fatal medication error. Becker’s Hospital CFO Report 2018; November 29, 2018
Sutton C, West E, Davis C. Second day of testimony concludes in trial for RaDonda Vaught, former Vanderbilt Medical Center nurse. NewsChannel5 Nashville 2022; March 24, 2022
ISMP (Institute for Safe Medication Practices). Safety Enhancements Every Hospital Must Consider in Wake of Another Tragic Neuromuscular Blocker Event. ISMP Medication Safety Alert! Acute Care Edition 2019; January 17, 2019
ISMP (Institute for Safe Medication Practices). Guidelines for the Safe Use of Automated Dispensing Cabinets. ISMP 2019; February 7, 2019
https://www.ismp.org/resources/guidelines-safe-use-automated-dispensing-cabinets
ISMP (Institute for Safe Medication Practices). Guidelines for Safe Electronic Communication of Medication Information. ISMP 2019; January 16, 2019
https://www.ismp.org/resources/guidelines-safe-electronic-communication-medication-information
ISMP (Institute for Safe Medication Practices). Challenges with Requiring Five Characters During ADC Drug Searches Via Override. ISMP Medication Safety Alert! Acute Care Edition 2021; October 21, 2021
American Nurses Association. Statement in Response to the Conviction of Nurse RaDonda Vaught. ANA March 25, 2022
American Organization for Nursing Leadership (AONL). Statement in Response to the Conviction of Nurse RaDonda Vaught, ANOL 2022; March 28, 2022
https://www.aonl.org/press-releases/Statement-in-Response-to-the-Conviction-of-Nurse-RaDonda-Vaught
Print “A Healthcare Worker’s Worst Fear”
April 19, 2022
Nursing Home Serendipity
Years ago, we encountered a serendipitous phenomenon in a nursing home. The nursing home, which had been running high rates of patient falls, suddenly had a dramatic drop in patient falls. It turned out that, due to a contractual issue, the consulting psychiatrist at the nursing home had ceased coming to the nursing home. As a result, a whole host of psychoactive medications had not been renewed on many patients. While the fall rates decreased, there did not appear to be any significant increase in other unwanted events. That led to the nursing home eventually re-evaluating the need for these medications on each patient and an overall reduction in the use of psychoactive medications in this patient population. The fall rate remained low.
We don’t recommend such a cataclysmic cessation of medications in nursing homes, but this occurrence was a valuable lesson in deprescribing.
Now, a new set of circumstances led to another valuable lesson. At the height of the COVID-19 pandemic, a large nursing home chain implemented a policy to temporarily hold potentially unnecessary medications. And,it turned out to be a good study on deprescribing.
McConeghy et al. (McConeghy 2022) describe the early months of the COVID-19 pandemic and challenges facing nursing homes (implementation of new quarantine and isolation practices, procurement, and use of personal protective equipment; daily symptom and exposure screens for staff and residents; adaptation of complex testing protocols; and clinical management of acutely ill residents. This occurred in the setting of staffing shortages due to staff illness and quarantine, disruption of supply chains for PPE and testing supplies, and a health system in crisis.
At that time, “crisis standards” wee proposed by long-term care experts (Wright 2021, Brandt 2020) in order to conserve critical nursing resources and PPE, and to limit exposure risk for residents by reducing unnecessary contact. One of the recommendations was to review medication regimens to identify medications that were of minimal clinical benefit and that could be either temporarily held or permanently discontinued. One large multistate long-term care provider implemented the "nonessential medication on hold" (NEMOH) policy. Nonessential medications were placed on a hold for a period of time, then providers could choose to restart or discontinue them. In essence, this became a deprescribing initiative. “Nonessential” medications in this population included: multivitamins, other vitamin supplements, herbal/naturopathic/homeopathic supplements, cranberry extract, antihistamines, decongestants, fish oil, probiotics, docusate, statins and all hyperlipidemia drugs, histamine-2 receptor agonists, and proton pump inhibitors. Prescribers were notified of the list of medications to be placed on hold and could override or 'opt-out' of individual hold orders. Every 2 weeks during the hold policy, the hold orders were reassessed by the prescribers and the facility's medical leadership (i.e., medical director).
The study population included 5126 residents in 64 nursing homes. Sixty-three percent (3247) of these residents with eligible medication(s) had at least one medication held during NEMOH. Overall, 5297 of 12,837 (41%) eligible medications were held. Of these held medications, 2897 (54%) were permanently discontinued at the end of the NEMOH period. In total, 23% of the original 12,837 nonessential medications identified at the beginning of the NEMOH period were discontinued.
There were some differences between residents whose medications were permanently discontinued and those who restarted at the end of the hold period. Residents with discontinued medications had more functional dependence, and were more likely to have do-not-resuscitate and do-not-hospitalize orders. Residents with discontinued medications were also more likely than those with restarted medications to be in smaller facilities and less likely to employ advanced practice clinicians.
Multivitamins, H2 receptor antagonists (H2RA’s), antihistamines, statins, proton pump inhibitors (PPIs), and probiotics were the most commonly held, whereas other vitamin supplements, cranberry extracts, docusate, fish oil, and the miscellaneous 'other' category were less likely to be held. Among the most prevalent held medications (statins, PPI’s, and multivitamins, the discontinuation incidences were 45.5%, 57.7%, 52.6% respectively.
Residents taking nonessential medications had these medications held for a median of 60 days, and when the hold policy was lifted, 54% of held medications were discontinued. The authors conclude that, although the policy was not originally envisioned as such, it became a relatively successful ad hoc deprescribing initiative. They suggest that the NEMOH policy acted as a “nudge” for uptake of deprescribing, but with lower stakes for unenthusiastic providers and residents. “In essence, we enacted a 'trial' deprescribing period of 60 days, and if the resident and prescribers agreed, this led to discontinuation of 54% of the held medications (22% of all eligible 'nonessential' medications).”
Nudges can be surprisingly powerful tools. We discussed “nudges” in our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts”. McConeghy et al. suggest that the NEMOH policy gave providers a set of cognitive clues (a "nudge") that they should consider deprescribing while also providing them a clear pathway through which they could implement the deprescribing.
Unfortunately, the McConeghy study did not include and statistics about unwanted outcomes, patient/family satisfaction, provider satisfaction, or unintended consequences.
Our March 2022 “MedSafer: Glass Half-Empty or Half-Full?” discussed MedSafer, a study (McDonald 2022), on electronic decision support for deprescribing in hospitalized older adults intended to answer the question of whether deprescribing actually translates to fewer adverse drug events (ADE’s). The study population was older (≥65 years) hospitalized patients with an expected survival of more than 3 months who were admitted to 1 of 11 acute care hospitals in Canada. So, it was not on nursing home patients. Though it found deprescribing increased from 29.8% in control patients to 55.4% in intervention participants, there was no difference in adverse drug withdrawal events between groups. However, there was no significant difference in the primary outcome, ADE’s within 30 days of discharge. The incidence of post-discharge falls did decrease but not statistically significantly. The authors noted that, while the intervention identified numerous deprescribing opportunities, many were for low-risk nonbeneficial polypharmacy (eg, nonstatin cholesterol-lowering medications or stool softeners) rather than for potentially inappropriate medications (PIM’s). They suggest that deprescribing these medications is less likely to impact 30-day ADE’s. The latter, of course, are the ones held in the McConeghy study. But McDonald et al. point out that deprescribing the “nonessential” medications still has both patient and societal value (avoiding excess cost, waste, pill burden, etc.).
The McConeghy study adds to a growing list of studies on deprescribing and includes a patient population (nursing home residents) in whom the potential benefits of deprescribing may be important. Hopefully, the study can serve as a template for nursing homes to take a stab at a deprescribing program.
Some of our past columns on deprescribing:
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
References:
McConeghy KW, Cinque M, White EM, et al. Lessons for Deprescribing From a Nonessential Medication Hold Policy in US Nursing Homes. J Am Geriatr Soc 2022; 70(2): 429-438
https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17512
Wright J. Crisis standards of care for the COVID-19 pandemic: an essential resource for the PALTC community. J Am Med Dir Assoc 2021; 22(2): 223-224
https://www.jamda.com/article/S1525-8610(20)31049-5/fulltext
Brandt N, Steinman MA. Optimizing medication management during the COVID-19 pandemic: an implementation guide for post-acute and Long-term care. J Am Geriatr Soc 2020; 68(7): 1362-1365
https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.16573
McDonald EG, Wu PE, Rashidi B, et al. The MedSafer Study—Electronic Decision Support for Deprescribing in Hospitalized Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2022; 182(3): 265-273 Published online January 18, 2022
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2788297
Print “Nursing Home Serendipity”
April 26, 2022
Challenges with Early Warning Systems
The concept behind early warning systems (EWS) is great. Theoretically, information from multiple sources can be aggregated and used to identify patients at risk for clinical deterioration before those caring for the patient might otherwise recognize.
But the success of early warning systems (and the associated rapid response systems) has been limited. We discussed barriers to success of these systems in our July 15, 2014 Patient Safety Tip of the Week “Barriers to Success of Early Warning Systems”.
A new study (Braun 2022) looks at early warning systems from a nursing perspective and has some important implications for design and implementation of such systems. Braun and colleagues interviewed nurses after implementation of a commercially available EWS algorithm. The algorithm collated data from a patient’s electronic health record (EHR), incorporating 26 EHR data points from laboratory values, vital signs, and nursing assessments. It then calculated a composite score, automatically updated as data were entered into a patient’s EHR. The healthcare team could view a patient’s EWS algorithm score, score trend and risk level via the patient’s EHR. The EWS algorithm triggered an alert when a patient’s score trended downward or fell below a threshold score.
A virtual care team (VCT) of 20 critical care nurse monitored the EWS algorithm alerts in real time, around the clock. When an EWS algorithm alert was triggered, the patient’s information would display on the shared monitor and the VCT nurse’s personal computer monitor. The assigned VCT nurse then followed a standardized protocol to briefly review the patient’s EHR before calling the patient’s acute care nurse to notify them about the EWS algorithm warning. The initial implementation had the VCT nurses calling the bedside nurse for every alert, but this was subsequently changed to allow VCT nurses discretion to not call on false-positive alerts.
Six principal themes emerged during the interviews of bedside nurses:
Timeliness
Because the bedside nurses were entering much of the information into the EHR, they were often aware of their patient’s deterioration and had already begun or completed the appropriate intervention before the EWS algorithm triggered and the VCT called. So, often the alert simply told them what they already knew and simply served as a distraction or interruption.
Workflow interruption
Those alerts and the calls from the VCT nurses often interrupted the bedside nurses while they were busy implementing the appropriate medical interventions.
Accuracy
Bedside nurses were often frustrated by false positives or false negatives. They often had to respond to calls for patients that were stable and they often did not get an alert or call on patients who were deteriorating. That undermined confidence in the EWS algorithm. Of interest is that the beside nurses often attributed false positives to the inclusion of subjective nursing assessment documentation. We had previously reported that inclusion of nursing impressions improved an EWS. But, in this study, the nurses placed little value on alerts that triggered based on such data due to inter-nurse variability.
Actionability
Some alerts had clear actions steps – such as activation of a rapid response team or transfer to an ICU. But others lacked good suggestions about next steps. Interestingly, “Some nurses appreciated the existence of the EWS programme as a safety net even though their clinical decision-making was rarely, if ever, impacted by the EWS programme.”
Underappreciation of core nursing skills
Many nurses felt that the EWS devalued their clinical skills and ability to recognize patients at risk for clinical deterioration. They also were concerned with the reliance on technology by a hands-on profession.
Opportunity cost
Many nurses felt that the money spent on the EWS would have been better used by hiring more staff. Yet, many appreciated the VCT nurses and sometimes called upon them for advice.
This study is, of course, reminiscent of alarm fatigue in an ICU or alert fatigue during CPOE. The basic problem seems to be presenting alerts that are neither timely nor actionable and are interruptive to normal clinical workflow.
The authors identified delays at multiple levels that contributed to frustration with the system. Delayed data input (charting) contributed to many of the problems encountered. But there were also delays due to the VCT nurses processing the alerts and delays in the VCT nurses contacting the bedside nurses, particularly when the VCT nurse could not reach the acute care nurse by phone in a timely fashion.
The Braun study does not describe how the charting and bedside nurse data input was handled. It says nurses reported a typical charting lag time of 0.5–2.5 hours, which would suggest to us that they were not using tablets or other input devices at the bedside.
As we said earlier, the value of an EWS is its ability to identify likely clinical deterioration in a patient before the clinical staff are aware of it. It sounds like the EWS in this study seldom did that. Couple that with the workflow interruptions and distractions caused by the EWS and it is no wonder nursing impressions of the system were not good.
Contrast that with the EWS discussed in our December 1, 2020 Patient Safety Tip of the Week “An Early Warning System and Response System That Work”. That system at Kaiser Permanente Northern California (KNPC) was based on data obtained from the electronic medical record (EMR). Predictors of events (unplanned transfers to the intensive care unit from a general med/surg floor) included laboratory tests, individual vital signs, neurologic status, severity of illness and longitudinal indexes of coexisting conditions, care directives, and health services indicators (e.g., length of stay). A score is generated and a threshold level was ascertained for prediction of events. For all three scores, about half of alerts occurred within 12 hours of the event, and almost two thirds within 24 hours of the event. Notably, the alerts provide 12-hour warnings and do not require an immediate response from clinicians. At the threshold used, the model generates one new alert per day per 35 patients. This minimized alert fatigue and did not cause the frequent workflow interruptions seen in the Braun study.
The ideal EWS works in the background, using data already available in the EHR and provides only alerts that are timely, accurate, actionable, and non-interruptive and don’t simply tell the clinicians what they were already aware of. The ideal EWS has not yet been implemented.
Some of our other columns on MEWS or recognition of clinical deterioration:
Our other columns on rapid response teams:
References:
Braun EJ, Singh S, Penlesky AC, et al. Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study. BMJ Quality & Safety 2022; Published Online First: 15 April 2022
https://qualitysafety.bmj.com/content/early/2022/04/14/bmjqs-2021-014498
Print “Challenges with Early Warning Systems”
May 3, 2022
Iatrogenic Burns Again
Our first exposure to iatrogenic burns was in a patient who woke up after surgery with a burn on his abdomen that had the shape of a medical instrument. During the surgery a “flash” sterilized instrument was requested. The surgeon noted it was too hot to handle and placed it on the drapes covering the patient. It cooled off enough after several minutes to be used. But, obviously, the duration of exposure to the heated instrument was long enough to cause the burn to the patient.
In our June 1, 2010 “Iatrogenic Burns” we noted 3 key conditions that predispose patients to burns. They are either insensitive to pain/temperature, unresponsive, or unable to communicate. There may be some additional predisposing factors, too, like impaired ability for the vasculature to help dissipate heat from the skin. And, of course, you need a heat source. And the duration of exposure is important. Lesser degrees of heat may cause burns when the duration of exposure is longer.
A recent report in the Anesthesia Patient Safety Foundation Newsletter described two consecutive patients suffering thermal injuries to the upper extremity and chest after the use of a convective warming system (Janik 2022). The cases were performed sequentially in the same operating room, with the same personnel. Both patients underwent a laparoscopic robotic prostatectomy in the Trendelenberg position with the arms tucked. In both cases, a convective warming system was used in conjunction with an upper body warming blanket. The article shows the configurations used. The hose was then connected to the warming blanket at the blanket port connection near the left shoulder. Notably, in one of the cases the air manifold was inadvertently missing. (The air manifold is an “elbow” shaped plastic tube connected to the end of the warming hose, with several openings on the distal end designed to evenly disperse warm air over the patient.) The warming device was set to a temperature of 44° Celsius (high setting) throughout both cases. Intraoperatively the warming device appeared to function normally, and the patients were normothermic. But, in recovery, both patients were noted to have diffuse erythema on the left upper extremity and chest, in close proximity to the site of the blanket port connection and, on postoperative day one, blistering developed on the shoulder and chest of both patients.
The authors note that the pattern of injury suggests a focal area of overheating at the point where the hose connects to the warming blanket. They also suspected there may have been a problem with the “over temperature” alarm. The absence of the air manifold also likely resulted in the concentrated delivery of warmed air onto a small surface area of the patient.
Janik et al. note the difficulties and challenges in recognizing a developing thermal injury. They note that clinical signs may not be present until well after the injury has occurred and that the site is often inaccessible or covered by the warming blanket itself or the surgical drapes. They also note that the lighting in an operating room may be dimmed, making detection of subtle erythema challenging.
One of the warnings in the instructions for use of the convective warming system is “To prevent thermal injury, do not use the highest temperature setting when treating patients who have decreased sensation, are nonsensate, or have poor perfusion.” Of course, since these patients are under anesthesia, they fit the definition of a patient at-risk. Yet, because of the desire to avoid hypothermia, these devices are frequently used.
They also note the importance of several warnings in the operating instructions for the devices. “Always start therapy on the lowest non-ambient temperature setting to prevent thermal injury. Increase the temperature setting, if required, using core body temperature and cutaneous response of skin in contact with the convective warming blanket as indicators.” “…Observe cutaneous response at regular intervals to prevent thermal injury. If erythema or instability in vital signs is evident, decrease the temperature setting or discontinue use of the convective warming therapy.”
Following these cases, they issued the following recommendations to anesthesia team members:
A response from the manufacturer (Cabrera 2022) stressed “The hose nozzle MUST be connected to a … convective warming blanket. Do not treat patients with the hose alone. Thermal injury may occur.” We discussed burns related to warming blankets in detail in our December 23, 2014 Patient Safety Tip of the Week “Iatrogenic Burns in the News Again”, in which we stressed the importance of avoiding “free hosing”. Cabrera also speculates that the extreme positions often used during robotic prostatectomies might have been a contributing factor and cautions that strict adherence to the operating instructions would be important in such cases.
We refer you back to our December 23, 2014 Patient Safety Tip of the Week “Iatrogenic Burns in the News Again” and an editorial accompanying the Janik article (Feldman 2022) for more detailed information on thermal injury related to warming blankets.
Ishikawa et al. (Ishikawa 2021) reported a case of a third-degree burn involving 5% of the total body surface area caused by off-label use of an infrared radiant heat lamp for bed-warming in a patient with severe accidental hypothermia. They caution that radiant heat lamps should never be used for rewarming of patients with hypothermia without careful observation. Note that we discussed burns related to fiberoptic light sources and halogen lamps in our March 2015 What's New in the Patient Safety World column “Another Source of Iatrogenic Burns”.
Andersen et al. did a review on iatrogenic burn injuries in an academic public hospital over a 15-year period (Andersen 2021). They found 122 patients who suffered iatrogenic burns, with fewer in 2013-2019 (2.9 ± 2.1 per year) compared to 2005-2012 (12.3 ±
4.1 per year). Most (41%) of the injuries occurred on the general medical floors, followed by the operating room (33.6%), intensive care unit (17.2%), and long-term care facilities (8.2%). The most common etiology was by scald mechanism by hot liquid (23%), followed by device (21.3%), heat pack (15.6%), and electrocautery (14.8%). The liquids included soup, hot water, and coffee.
Device-related burns were associated with high flow nasal cannula, endovascular scope light, bipolar and coblator, drill guard, forced-air patient warming system, ultrasound assisted liposuction system, and endoscopic/laparoscopic light cords. Electrocautery devices alone made up 14.8% of iatrogenic burns.
Less common etiologies included food, defibrillator, radiation, curling iron, hot glue gun, cooking equipment, EEG pads, pulse oximetry sensor, and a cooling blanket. The most common location injured was the leg (15.6%), followed by the abdomen (12.3%), back (8.2%), and arm (7.4%). The frequent occurrence on the abdomen and legs was attributed to many spills occurring in sitting patients. Overall, burns were more often attributed to medical personnel rather than patients themselves.
While all categories of causes declined over the duration of the study, device-related burns especially declined. The authors felt this may be explained by increased awareness and handling of medical devices in the operating room, including health system implementation of the “time-out” procedure discussing fire risks prior to starting surgical procedures.
The authors had several recommendations. Temperature control of soups, hot water, coffee, and other solid foods should be achieved prior to serving or presenting these meals to patients. Care should especially be taken when serving young children, older adults, and people with disabilities who are at higher risk for serious injury from hot food and beverage scalds. They also note that increased communication about fire risk and roles of team members in the event of an operating room fire may help further decrease the incidence of burns sustained by patients within the operating room.
The problem of burns related to dietary spills was highlighted in a review by the Pennsylvania Patient Safety Authority (Field 2018) that we discussed in our June 5, 2018 Patient Safety Tip of the Week “Pennsylvania Patient Safety Authority on Iatrogenic Burns”.
Another unusual cause for iatrogenic burns was recently reported (Lewis 2020). Hot water immersion (HWI) is a method used for treating marine stings and marine envenomations (Atkinson 2006). Application of hot, but not scalding, water (42-45 °C) for 30-90 minutes or until the pain resolves, seems to be standard advice, though some patients may find such temperatures difficult to tolerate. Atkinson et al. recommend use the highest temperature that can be applied safely and that is tolerable. But there is danger of iatrogenic burns with HWT. Lewis et al. (Lewis 2020) found 9 cases of iatrogenic burns from use of HWT over a 5-year period that were referred to a State Adult Burn Service. All patients continued unsupervised HWI at home and sustained thermal injury to their feet. The authors recommend that, while heat application is an effective treatment for marine stings, further patient education is required following discharge from point of care. They recommend that first-aid treatment guidelines be updated to reflect that patients are not recommended to continue scalding water immersion at home. However, if patients wish to continue HWI, water temperature should be checked manually with a thermometer or with a nonstung limb and limited to 30 minutes immersion, with 30-minute skin recovery time between.
We discussed burns related to electrosurgical devices in our Patient Safety Tips of the Week for September 5, 2017 “Another Iatrogenic Burn” and July 28, 2020 “Electrosurgical Safety”. We noted that one of the most serious thermal injuries is that caused by electrocautery devices during abdominal or pelvic surgery, which is often unrecognized during the surgery. The thermal damage often leads to delayed tissue necrosis and subsequent leaks from bowel, ureter or other viscus. So, symptoms and signs often do not appear for several days.
Another device implicated in iatrogenic thermal injuries is the dental handpiece. See our October 5, 2010 Patient Safety Tip of the Week “More Iatrogenic Burns” for details.
And don’t forget the risk of burns and thermal injury related to metallic or ferromagnetic materials during MRI scanning. Burns can result when any object containing metallic or ferromagnetic material superheats during the scan. While most burns have occurred due to things like superficial EKG electrodes or coils, the risk of thermal injury has also been attributed to some unusual items: transdermal skin patches, tattoos, tags on breast implants, ingested toy magnets, and even metallic eyelashes (see our previous columns for April 2, 2019 “Unexpected Events During MRI” and September 2019 “New MRI Hazard: Magnetic Eyelashes”). But the COVID-19 pandemic led to a new culprit for MRI-related burns – face masks (see our January 2021 What's New in the Patient Safety World column “New MRI Risk: Face Masks”). The FDA issued a warning after receiving a report of a patient suffering facial burns from a face mask during MRI (FDA 2020). Some face masks and respirators contain metal parts or coatings. The FDA notes that metal parts, like nose pieces nose clips or wires, headband staples, nanoparticles (ultrafine particles), or antimicrobial coating that may contain metal (such as silver or copper), may become hot and burn the patient during an MRI. The FDA acknowledges that it may be appropriate for a patient to wear a face mask during an MRI exam, especially during the COVID-19 pandemic. But it is critical to ensure the face mask contains no metal.
It's worth repeating recommendations in our September 5, 2017 Patient Safety Tip of the Week “Another Iatrogenic Burn” that your organization should do to minimize the risks of iatrogenic burns:
And Cynthia Field’s recommendations from the PPSA review (Field 2018):
The PPSA Advisory by Field is an important contribution to the relatively scant literature on iatrogenic burns in healthcare, It especially draws attention to the risks of food and beverages that have largely been ignored in the past. We obviously need to pay more attention not only to the temperature of foods and beverages but also to the likelihood that they might be spilled onto the patient due to patient-related factors or environmental factors.
Our prior columns on iatrogenic burns:
References:
Janik LS, Lewandowski R. Thermal Injury After Use of a Convective Warming System. APSF Newsletter 2022; 37(1): 19-21
https://www.apsf.org/article/thermal-injury-after-use-of-a-convective-warming-system/
Cabrera JA. Convective Warming Systems – Maintaining Normothermia in the Operating Room. APSF Newsletter 2022; 37(1): 21-22
Feldman J. Convection Warmers and Burn Injury – Still A Clear and Present Danger. APSF Newsletter 2022; 37(1): 23
https://www.apsf.org/article/convection-warmers-and-burn-injury-still-a-clear-and-present-danger/
Ishikawa K, Maeda T, Hayashi T, et al. Iatrogenic third-degree burn caused by off-label use of an infrared radiant heat lamp in a patient with accidental hypothermia. Burns Open 2021; 5(1): 21-24
https://www.sciencedirect.com/science/article/pii/S2468912220300547
Andersen ES, Powell LE, Marcaccini RL, Feldman MJ, Drake MD. A 15-Year Review of Iatrogenic Burn Injuries in an Academic Public Hospital. J Burn Care Res 2021; 42(5): 894-899
https://academic.oup.com/jbcr/article-abstract/42/5/894/6290181?redirectedFrom=fulltext&login=false
Field C. Hot Topic: Nonsurgical, Healthcare-Associated Burn Injuries. Pa Patient Saf Advis 2018; 15(1).
http://patientsafety.pa.gov/ADVISORIES/Pages/201803_BurnInjuries.aspx
Lewis CJ, Wood F, Goodwin-Walters A. Iatrogenic Thermal Burns Secondary to Marine Sting Treatment. J Burn Care Res. 2020 Jul 3;41(4):878-881
https://academic.oup.com/jbcr/article-abstract/41/4/878/5788260?redirectedFrom=fulltext&login=false
Atkinson PR, Boyle A, Hartin D, McAuley D. Is hot water immersion an effective treatment for marine envenomation? Emerg Med J. 2006; 23(7): 503-508
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579537/
FDA (US Food and Drug Administration). Wear Face Masks with No Metal During MRI Exams: FDA Safety Communication. FDA 2020; December 7, 2020
Print “Iatrogenic Burns Again”
May 10, 2022
Dilaudid - Again!
One of our most frequent topics has been opioid-induced respiratory depression (OIRD) and another frequent topic has been dangers specifically associated with Dilaudid. Recent revelations from a malpractice case (Aguirre 2022a, Aguirre 2022b) bring both issues into the news.
A 28 y.o. man donated a kidney for transplant to his 30 y.o. woman. The recipient, his sister, did well after the transplant surgery. But the donor did not do well and ended up dying.
Details were only available from the media reports noted above, which show that a court ruled the hospital fell below the standard of care in treating [patient], resulting in "death from opioid overdose". We should note that the hospital disputes that conclusion in a statement issued after the media reports.
The patient complained of severe pain post-operatively and received substantial amounts of opioids via PCA (patient-controlled analgesia) pump. He was not monitored with pulse oximetry nor were vital signs being monitored frequently. On the morning of the day after surgery, he asked his mother for his sunglasses so he could go to sleep. Shortly thereafter, his mother noted him to be cold and not breathing. A Code Blue was called. A heartbeat was restored but he had sustained severe hypoxic/ischemic encephalopathy and 9 days later life support was removed.
His mother was told that perhaps he had “a genetic heart defect” that led to cardiac arrest. However, she sought his medical records. After she was given only 40 pages of his records, she hired a malpractice attorney, who was able to get over 44,000 pages! At the trial, medical experts noted that he was not on pulse oximetry and had not had his vital signs recorded for nearly 5 hours, stating that these did not meet the expected standards of care. A pharmacist serving as an expert witness noted multiple failures in his care but specifically focused on the amount of Dilaudid given, noting that medical, nursing, and pharmacy staff did not seem to be aware of the relative potency of Dilaudid, and the possible need to use lower doses in someone who had just donated one of his kidneys. He also noted that, during the resuscitative efforts, Narcan was not administered to counter the effects of the opioids.
The media report (Aguirre 2022b) provides a timeline of the events that took place. While he was receiving Fentanyl via PCA pump post-operatively, he complained of severe pain about 2 hours after the surgery. Because the Fentanyl did not adequately control his pain, an order was written for Dilaudid via PCA pump (“0.6mg/15min ~ 2.4mg. per hour max”). The timeline appears to show he received 11.4 mg of Dilaudid over roughly 14 hours. He also vomited multiple times throughout the evening, night and following morning. At 4:30 AM on the morning following surgery, his last vital signs were taken. It was at 9:17 AM that his mother noted he was cold and not breathing and the Code Blue was called at 9:18 AM.
When his mother had responded to his request for sunglasses, she also took a photo of him. That apparently proved to be important in the malpractice action, since it showed he was not on pulse oximetry. As noted above, the hospital still disputes that the patient died from an opioid overdose, stating “the patient’s clinical course was not consistent with excessive opioids as the cause of death.” However, following the incident, the hospital did change its policy so that transplant patients are now monitored with continuous pulse oximetry. The hospital statement notes “At the time, [the hospital] did not use continuous pulse oximetry monitoring for transplant patients who were on a self-controlled analgesic pump (PCA) to provide pain relief following surgery. National guidance for pulse-oximetry with a PCA continues to evolve but remains at the discretion of providers. However, out of an abundance of caution, we modified our [hospital] transplant program protocol after this incident to include continuous pulse-oximetry monitoring for all patients on a PCA for post-operative pain control.”
The case highlights a point we often make – there really is no such thing as a “low risk patient” when it comes to post-op opioid-induced respiratory depression. We recommend continuous monitoring of such patients, not only with continuous pulse oximetry but also with capnography.
The media reports note that there is currently a new bill before Congress, the In-Patient Opioid Safety Act, that would require all patients on opioids in hospitals to have continuous monitoring.
The media reports also refer to the excellent review from Dartmouth-Hitchcock Medical Center (McGrath 2021) on inpatient respiratory arrest associated with sedative and analgesic medications and the impact of continuous monitoring on patient mortality and severe morbidity. McGrath et al. found that no patient with continuous monitoring died (of 111,488 discharges in units with surveillance monitoring in place, the only death was in a patient not actually being monitored). There were 3 deaths among the 15,209 discharges in unmonitored units.
But the case also points out the frequent problem of underestimating the relative potency of Dilaudid (HYDROmorphone). While estimates of equipotency vary considerably in the literature, most now agree that 1 mg. of Dilaudid is probably the equivalent of 5-7 mg. of morphine. We often quote Chang and colleagues (Chang 2010) who noted several years ago that emergency room physicians and nurses who were hesitant to administer 7 to 10 mg. of morphine were not reluctant to administer 1 to 1.5 mg. of Dilaudid. They point out this is an illusion that less narcotic is being used with that Dilaudid dose. We don’t know enough detail in the current case to know whether the relative potency issue was truly a factor or not. The main issue in the case was the lack of monitoring. But it is still a good time to reiterate the dangers of Dilaudid.
To reiterate from our multiple columns on Dilaudid dangers (see the columns listed below), here are strategies you should consider to reduce the risk of Dilaudid/HYDROmorphone (and other opioid) adverse events:
As an aside, there is one other condition we always consider when we encounter a sudden unexplained death in the hospital. That is Torsade de pointes (see our June 25, 2019 Patient Safety Tip of the Week “Found Dead in a Bed – Part 2”). The media reports provide no details about the EKG’s. The patient in this case did have multiple episodes of vomiting and was given Zofran, one of the many drugs that may prolong the QTc interval. It is conceivable that, perhaps combined with some electrolyte disturbance related to the protracted vomiting, Zofran might have led to QTc prolongation and torsade. We would assume that the analysis of the incident would have looked for that possibility.
Our prior columns on patient safety issues related to Dilaudid/HYDROmorphone:
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
References:
Aguirre J, Campos R, Carroll J, Villarreal M. Simple Device Could Have Saved Life of Young Kidney Donor. NBCBayArea.com 20222; May 4, 2022 Updated on May 5, 2022
Aguirre J, Campos R, Carroll J, Villarreal M. Dozens of Mistakes Caused Death of Young Hospital Patient, Court Rules. NBCBayArea.com 20222; May 5, 2022
McGrath SP, McGovern KM, Perreard IM, Huang V, Moss LB, Blike GT. Inpatient Respiratory Arrest Associated With Sedative and Analgesic Medications: Impact of Continuous Monitoring on Patient Mortality and Severe Morbidity. J Patient Saf 2021; 17(8): 557-561
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8612899/
H.R.5932 - Inpatient Opioid Safety Act of 2021
https://www.congress.gov/bill/117th-congress/house-bill/5932/text?r=6&s=1
Hospital Response to NBC Bay Area Nov. 2, 2021
https://www.documentcloud.org/documents/21857280-ucsf-statement
Chang AK, Bijur PE, Meyer RH, et al. Safety and Efficacy of Hydromorphone as an Analgesic Alternative to Morphine in Acute Pain: A Randomized Clinical Trial. Ann Emerg Med 2006; 48: 164-172
https://www.annemergmed.com/article/S0196-0644(06)00398-2/fulltext
Print “Dilaudid – Again!”
May 17, 2022
Patient Harm in Medicare Inpatients
Back in 2010, a report from the Inspector General of U.S. Health and Human Services (Levinson 2010) found that 27% of Medicare patients hospitalized in 2008 had either an “adverse event” or a “temporary harm event” and that 44% of these were potentially preventable. That report was an eye opener for many.
Fast forward 10 years and not much has changed. The just released OIG report (Grimm 2022) found that 25% of Medicare patients hospitalized in 2018 had either an “adverse event” or a “temporary harm event” and that 43% of these were potentially preventable.
Adverse events were defined as events that led to longer hospital stays, permanent harm, life-saving intervention, or death. Twelve percent of hospitalized Medicare patients experienced an adverse event in the current study. Temporary harm events were defined as those events that required intervention but did not cause lasting harm, prolong hospital stays, or require life-sustaining measures. Thirteen percent of hospitalized Medicare patients experienced a temporary harm event in the current study.
The study was based on a sample of 770 Medicare patients discharged from acute care hospitals in October 2018. Nurses used a trigger tool (a modified version of IHI’s global trigger tool) to identify adverse events and temporary harm events. Physician reviewers then determined whether an identified event was potentially preventable.
Events related to medications were the most frequent (43%), followed by other patient care (23%), surgery (22%), and infections (11%).
Notably, HAC’s or hospital-acquired conditions, which have traditionally been the most reported events by CMS, accounted for only a small fraction of the events reported in the current study. Of the harm events identified in the current study, only 5 percent were on CMS’s HAC Reduction Program list and only 2 percent were on CMS’s Deficit Reduction Act HAC list.
In our February 2012 What's New in the Patient Safety World column “OIG: Hospitals Fail to Report Most Cases of Harm” we cited another report by the OIG (Levinson 2012) which found that, although all hospitals have incident reporting systems and other systems to identify adverse events, only 14% of hospital adverse events get reported. The commonest reasons given for lack of reporting were that the event was not related to an “error” or the event was considered to be an expected outcome or expected adverse event or that any harm involved was considered to be minor or temporary or simply that the hospital had no master list of reportable events. As in all studies of incident reporting, most reports are done by nursing, and physicians seldom report adverse events. About a quarter of the adverse events were ones usually reported but were not reported in this instance.
CMS, of course, is interested not only in the human toll related to harm events but also in the costs incurred by Medicare as a result of these events. The report estimated the costs for all events (preventable or non-preventable) to be in the hundreds of millions of dollars for October 2018.
The report suggests that the current Medicare event reporting needs to be reformed. It notes that the physician reviewers determined that 56 percent of harm events were not preventable and occurred even though providers followed proper procedures. The overall harm rate would be 13 percent if only events determined were preventable were included. As such, the report recommends that CMS update and broaden its lists of HAC’s to capture common, preventable, and high-cost harm events.
The report also recommends CMS explore expanding the use of patient safety metrics in pilots and demonstrations for health care payment and service delivery. It also recommends that CMS develop interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm. It also had several recommendations for AHRQ on promoting patient safety.
There has been considerable controversy over the years about the exact frequency of harm related to medical care. We’ve discussed this in our August 2019 What's New in the Patient Safety World column “How Often Do Preventable Errors Occur?” and the other columns listed below. Bottom line: regardless of the exact number, there are simply too many. Most bothersome is the fact that there has been little change in the CMS findings 10 years after their first report.
How dangerous is a day in the hospital? For many years, we have used the numbers from a study done by Lori Andrews et al. (Andrews 1997) that found you have a 6% chance per inpatient day of having an adverse event that could impact your health. A study (Hauck 2011) quantified the risk even further. Using a large database from public hospitals in Australia, the authors calculated that the average hospital stay carries a 5.5% risk of adverse drug reaction, 17.6% risk of infection, and 3.1% risk of pressure ulcers. Moreover, each additional night in the hospital increases the risk by 0.5% for adverse drug reactions, 1.6% for infections, and 0.5% for pressure ulcers.
So, got all those numbers? You’ll forget them and those in the current OIG report shortly. You’ve often heard us use the phrase “Stories, Not Statistics” (see our December 2009 What’s New in the Patient Safety World column “Stories, Not Statistics”). When we first began doing presentations on patient safety in the early 1990’s we often began with some of the statistics on medical error from Lucien Leape’s work. But we began to notice physicians and medical students begin to zone out when we talked about statistics on medical error. What got their attention were the anecdotes we would tell about cases that really happened. So, we changed our focus. While we still often show statistics on medical error to put things in context, we no longer highlight them. Instead, we really rely on the stories. That’s what makes people say “I wonder if that could happen here?” and what makes them go back to look at the systems in their health care systems. It is those stories that hit home hard and make people remember. Who cannot remember their own reactions when they first heard the Josie King story, or the story about the nurse who administered Bicillin intravascularly, or the little boy who died from concentrated epinephrine injection during a simple surgical procedure, or any nurse who inadvertently administered concentrated potassium solutions? Or the recent tragic events related to inadvertent administration of a neuromuscular blocking agent (NMBA) that led to the conviction of a nurse for negligent homicide (see our April 12, 2022 Patient Safety Tip of the Week “A Healthcare Worker’s Worst Fear”)?
In fact, the lack of compelling stories like these is the prime reason we feel IOM’s “To Err is Human: Building a Safer Health System” failed to gain traction despite considerable initial media attention. Everyone focused on the statistics from that report. It lacked the stories about real people you need to tell in order to get people and systems to change.
The current CMS report does have several “patient stories” and an appendix that provides brief examples of some of the harmful events found in their sample. But these have such limited detail that they do not tell compelling stories. We’ve always felt that the failure to share root cause analyses and lessons learned from significant healthcare incidents has been the biggest barrier to improving patient safety. PSO’s have yet to live up to their potential to share such lessons and, even then, they only share among their members Thus, those lessons reach only a tiny fraction of healthcare organizations that could benefit from sharing.
See some of our prior columns on the frequency of harmful medical errors:
References:
Levinson DR. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090
http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf
Grimm CA. (Office of the Inspector General U.S. Department of Health and Human Services). Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. May 2022
https://oig.hhs.gov/oei/reports/OEI-06-18-00400.pdf
Levinson DR. (Office of the Inspector General. Department of Health and Human Services). Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. January 2012
http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf
Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997; 349: 309–313
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2896%2908268-2/fulltext
Hauck K, Zhao X. How Dangerous is a Day in Hospital?: A Model of Adverse Events and Length of Stay for Medical Inpatients. Medical Care 2011; 49(12): 1068-1075, December 2011
Print “Patient Harm in Medicare Inpatients”
May 24, 2022
Requiring Indication for Antibiotic Prescribing
Including the indication on prescriptions and medication orders is an important patient safety intervention. Our multiple columns on this issue, listed below, have outlined the benefits of including the indication.
There is one area where including the indication is particularly important – prescribing antibiotics. Knowing exactly why or for what infection the antibiotic is being ordered can be an important part of every antibiotic stewardship program, whether at the hospital or clinic/office. An antibiotic stewardship program can help determine whether the specific antibiotic, dose, or duration is appropriate for the intended infection.
The core elements of CDC’s “Core Elements of Hospital Antibiotic Stewardship Programs” (CDC 2019) include documentation of dose, duration, and indication for all antibiotic orders. CDC notes that requiring an indication for antibiotic prescriptions can facilitate other interventions, like prospective audit and feedback and optimizing post-discharge durations of therapy, and, in and of itself, can improve antibiotic use.
One question often asked is “Are the indications actually accurate?”. One study (Heil 2018) found that they are accurate. Heil et al. reviewed 396 antibiotic orders in a pediatric ICU and adult medicine step-down unit and found 90% agreement between provider-selected indication and independent review. That was similar to the 86% accuracy in a random sample of 50 orders for antimicrobial treatment in a study by Patel et al. (Patel 2012). Heil et al. conclude that prompts to enter antibiotic indication during order entry provide largely accurate information. They suggest that accuracy could be further improved by an electronic order entry system prompt to re-enter the antibiotic indication between 48 and 72 hours.
The accuracy of the antibiotic indication documented in the order may vary somewhat by specific antiobiotic. Timmons et al. (Timmons 2018) reviewed 155 antibiotic orders. Clinical documentation supported the entered indication in 80% of vancomycin orders, 78% of cefepime orders, and 74% of fluoroquinolone orders. The clinical appropriateness for vancomycin, cefepime, and fluoroquinolones were 94%, 100%, and 68%, respectively. They also noted that, when providers chose indications from the list as opposed to choosing “other” and entering free text, antibiotic orders were significantly more likely to be appropriate but also less likely to match clinical documentation.
Antibiotic stewardship on the outpatient side is more complex and it is particularly important to know the indication for the antibiotic. Neels et al. (Neels 2020) note many factors that contribute to inappropriate antibiotic prescribing in general practice. These include automatic repeat prescriptions, inappropriate durations and quantities and the extended period of time during which a prescription may be filled. In addition, some prescriptions are dispensed more than 60 days after the prescription date, suggesting likely usage for an alternate indication to that intended by the prescriber. Patient expectations may also lead to inappropriate antibiotic prescribing. They implemented an educational intervention in a large general practice clinic in Australia. It included face-to-face education sessions with physicians on antimicrobial stewardship principles, antimicrobial resistance, current prescribing guidelines and microbiological testing. This resulted in a significant reduction in prescriptions without a listed indication for antimicrobial therapy, prescriptions without appropriate accompanying microbiological tests and the provision of unnecessary repeat prescriptions. There were significant improvements in appropriate antimicrobial selection, appropriate duration, and compliance with guidelines.
Ray et al. did a national cross sectional study of antibiotic prescribing without documented indication in ambulatory care clinics (Ray 2019). Antibiotics were prescribed during 13.2% of the estimated 990.8 million ambulatory care visits in 2015. 57% of the 130.5 million prescriptions were for appropriate indications, 25% were inappropriate, and 18% had no documented indication. Being an adult male, spending more time with the provider, and seeing a non-primary care specialist were significantly positively associated with antibiotic prescribing without an indication. Sulfonamides and urinary anti-infective agents were the antibiotic classes most likely to be prescribed without documentation.
Saini et al. (Saini 2022) recently did a literature review on documentation of the indication for antimicrobial prescribing. They identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%–100%). A benefit to prescribing or patient outcomes was identified in 17 of 19 studies that looked at these end points. They note that several studies have shown that multipronged approaches can be used to improve this practice and that emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes in both community and hospital settings. However, they conclude that setting-specific and larger trials are needed to provide a more robust evidence base for this practice.
An overview on improving antimicrobial documentation by Public Health Ontario noted several approaches (Public Health Ontario 2016). In addition to educational efforts, chart stickers, specific antimicrobial charting forms, and a place of prominence in the chart or medication administration record for recording details of antimicrobial therapy are all ways of improving antimicrobial documentation. Antimicrobial documentation can also be facilitated by using computerized physician order entry systems; by requiring physicians to document certain information before finalizing an order; and/or by specifying a rationale for opting out of a protocol (e.g., ordering antimicrobials for a longer duration than recommended).
Today’s CPOE systems and ePrescribing systems should prompt for indication any time an antimicrobial is being ordered or prescribed. Dtop-down lists should be as specific as possible and try to avoid using an “other” category as much as possible. Knowing the indication for an antimicrobial is critical for successful antimicrobial stewardship programs and for promoting good patient outcomes.
Some of our other columns on including indication for medication orders:
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
March 1, 2022 “Including the Indication on Prescriptions”
Some of our prior columns on antibiotic stewardship:
References:
CDC (Centers for Disease Control and Prevention). Core Elements of Hospital Antibiotic Stewardship Programs. CDC 2019
https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
Heil EL, Pineles L, Mathur P, et al. Accuracy of Provider-Selected Indications for Antibiotic Orders. Infect Control Hosp Epidemiol 2018; 39(1): 111-113
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352307/
Patel JA, Esterly JS, Scheetz MH, Postelnick MJ. An analysis of the accuracy of physician-entered indications on computerized antimicrobial orders. Infect Control Hosp Epidemiol 2012; 33: 1066-1067
Timmons V, Townsend J, McKenzie R, Burdalski C, Adams-Sommer V. An evaluation of provider-chosen antibiotic indications as a targeted antimicrobial stewardship intervention. American Journal of Infection Control 2018; 46(10): 1174-1179
https://www.ajicjournal.org/article/S0196-6553(18)30215-3/fulltext
Neels AJ, Bloch AE, Gwini SM, Athen E. The effectiveness of a simple antimicrobial
stewardship intervention in general practice in Australia: a pilot study. BMC Infectious Diseases 2020; 20: 586
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05309-8
Ray M J, Tallman G B, Bearden D T, Elman M R, McGregor J C. Antibiotic prescribing without documented indication in ambulatory care clinics: national cross sectional study BMJ 2019; 367: l6461
https://www.bmj.com/content/367/bmj.l6461
Saini S, Leung V, Si E, et al. Documenting the indication for antimicrobial prescribing: a scoping review. BMJ Quality & Safety 2022; Published Online First: 12 May 2022
https://qualitysafety.bmj.com/content/early/2022/05/12/bmjqs-2021-014582
Public Health Ontario. Antimicrobial Stewardship Strategy: Improved antimicrobial documentation. March 28, 2016
Print “Requiring Indication for Antibiotic Prescribing”
May 31, 2022
NHS Serious Incident Response Framework
It has been 15 years since we first posted advice on responding to serious patient safety events (see our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist”). Our sample Serious Incident Response Checklist is still a good place to start.
The UK’s National Health Service is in the process of updating its Patient Safety Incident Response Framework (NHS 2020a). Their previous framework was adopted in 2015 (NHS 2015). But, in part because a report showed multiple deficiencies in the way some hospital trusts were dealing with incidents, the need for an update became apparent. That report (CQC 2016) found that interactions with patients and families after deaths or serious incidents were suboptimal and that the incident investigations were not being done in a manner that would promote learning from them. And the issue of accountability was not well handled. NHS is currently piloting the updated version (NHS 2020b) with a set of “early adopters” and expects that the new framework will be adopted by all in autumn 2022.
The revised framework (NHS 2020b) notes that organizational behaviors required in the approach should reflect three main principles:
One important change in the new revision is moving away from strictly defined serious incidents and using the framework in a manner that focuses on any incident that might lead to organizational learning. Note that the NHS approach replaces the term root cause analysis (RCA) with “systems-based patient safety incident investigation”. The primary focus of the investigation is to promote learning rather than focusing on individual performance.
The new version also adopts Just Culture for a fair and equitable response to patient safety incidents. One really nice feature of the NHS framework is a Just Culture Guide. This takes the investigator or manager through a series of questions to determine whether the behavior of an individual involved in an incident fits one of the 3 main categories in the Just Culture framework. Based on the responses to the questions, recommended actions are suggested. Questions are:
1a. Was there any intention to cause harm?
2a. Are there indications of substance abuse?
2b. Are there indications of physical ill health?
2c. Are there indications of mental ill health?
3a. Are there agreed protocols/accepted practice in place that apply to the action/omission in question?
3b. Were the protocols/accepted practice workable and in routine use?
3c. Did the individual knowingly depart from these protocols?
4a. Are there indications that other individuals from the same peer group, with comparable experience and qualifications, would behave in the same way in similar circumstances?
4b. Was the individual missed out when relevant training was provided to their peer group?
4c. Did more senior members of the team fail to provide supervision that normally should be provided?
5a. Were there any significant mitigating circumstances?
That question 4a is the most important question we usually ask when doing a root cause analysis: “How likely is it that another individual, given the same set of circumstances, might have thought or acted in the same manner?”
The updated framework cautions against hindsight bias or other biases that might interfere with conclusions of an investigation.
The updated version sets expectations for informing and supporting patients, families and carers involved in patient safety incidents. It also sets expectations for informing and supporting staff involved in patient safety incidents.
One stated principle is that all healthcare professionals also have a professional responsibility to be honest with patients when things go wrong. It also says that organizations should seek feedback from patients, families and carers to determine how well they are upholding the principles of openness and transparency. This feedback can come from conversations with staff supporting those affected or be retrospectively sought after an organization concludes its response to an incident. A series of patient videos is provided, demonstrating how patients responded to being in the loop in the incident investigation process.
Consistent with the primary goal of learning from incident investigations, the framework states that organizations must be able to apply knowledge of the science of patient safety and improvement to identify:
The framework includes the following steps:
NHS also has a template to help guide hospitals/trusts in developing their patient safety incident response plan.
The updated NHS is remarkably similar to the our recommendations highlighted in our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist”. We developed that sample Serious Incident Response Checklist because many hospitals were still struggling with their root cause analyses of serious adverse events. One of the problems is just getting started promptly. One of the keys to good incident investigation is obtaining all the factual evidence as soon as possible. Particularly when it comes to interviewing witnesses, it is important to remember that memory of the event becomes less clear with passage of time and those memories may even be changed by other events, conversations, etc. It is extremely important that we understand how the participants in the incident perceived the unfolding situation and events as they occurred, rather than reinterpreting them after knowledge that the outcome was adverse.
Therefore, each hospital should have a Serious Incident Response policy and checklist to help guide them in their response to a serious incident.
Obviously, the individual assigned responsibility for each task may vary from organization to organization. But having the task listed on a checklist and and individual designated helps everyone remember what needs to be done.
In the US, the “serious incident” might meet the Joint Commission definition of a Sentinel Event or the state health department definition of a serious reportable event but you should also consider even near-misses as meeting the definition if there was potential for a serious adverse patient outcome. On receiving the incident report, the designated individual (usually a risk manager) should immediately discuss the incident with the medical director, director of nursing and director of quality improvement to decide whether the Serious Incident Investigation Team/RCA Team should be convened. The risk manager (or other designated person) should contact the supervisor of the area where the incident occurred to ensure that all potential witnesses are identified and then schedule a meeting of the Team as soon as possible (usually within one day). In those cases where a witness will be unavailable to be interviewed in person, arrangements can usually be made for that person to be interviewed by phone.
The chart of the patient should be secured and working copies made for use by the Team. When we originally developed our checklist, many facilities had not yet transitioned to electronic medical records. One reason for securing the paper record was to ensure that no changes were made to the original record. The timestamps on electronic medical records largely change the need for that. However, making working copies for the Team to review may still be useful.
Importantly, any equipment or devices involved in the incident should be sequestered. That is to ensure that the equipment is available for the investigation and also to ensure that any potentially faulty equipment is not used for another patient.
We believe that the patient and/or family should be notified early that errors may have occurred and that the incident is being investigated. We’ve long been believers in being very forthright with patients/families and telling them when there were mistakes made in their care. Subsequent research and other experience certainly seems to bear out that such an approach and an apology are important when mistakes or errors did impact on the outcome. The details and the apology, of course, cannot be given until the RCA is complete and all contributing factors known. However, our experience is that patients and families appreciate candor and should be told that an investigation is ongoing and that they will be made aware at some point of at least the general outcome of that investigation. It should be made clear to them that the investigation is being done to help ensure that similar events do not occur in the future. The individual who speaks to the patient or family should usually be the one with the best pre-existing rapport. That is usually the attending physician but may under some circumstances be someone else in the organization. If it is awkward for the attending physician to speak to the family, then the medical director is an appropriate individual to speak to them.
Most of the other items in the check list are self-explanatory (mostly notification to various agencies and bodies of the incident occurrence). Some state Department of Health offices require notification of certain events within 24 hours. Even if that is not a formal requirement, a good general rule is to notify them of any event that is likely to attract press attention. That way the state department is not taken by surprise if an inquiry is made and they are able to respond that they are aware of the incident and the ongoing investigation.
The last item is very important and often overlooked. Caregivers undergo a variety of deep emotions when one of their patients is harmed, particularly when they feel they may have contributed in some way to that adverse outcome. So each organization should have some mechanism for providing needed support and assistance to any physicians, nurses, pharmacists, etc. that may have been directly involved in the incident or had been actively involved in the care of the patient.
Our many columns on root cause analyses reflect the need to use them as learning tools. But we always emphasize that we should not wait for incidents to occur. Doing FMEA’s (failure mode and effects analyses) is an important way to identify potential vulnerabilities before an incident actually occurs. The new NHS framework also encourages organizations to be proactive in a similar manner.
Some of our prior columns on RCA’s, FMEA’s, response to serious incidents, etc:
July 24, 2007 “Serious Incident Response Checklist”
March 30, 2010 “Publicly Released RCA’s: Everyone Learns from Them”
April 2010 “RCA: Epidural Solution Infused Intravenously”
March 27, 2012 “Action Plan Strength in RCA’s”
March 2014 “FMEA to Avoid Breastmilk Mixups”
July 14, 2015 “NPSF’s RCA2 Guidelines”
July 12, 2016 “Forget Brexit – Brits Bash the RCA!”
May 23, 2017 “Trolling the RCA”
October 2019 “Human Error in Surgical Adverse Events”
January 2020 “ISMP Canada: Change Management to Prevent Recurrences”
October 2020 “Common Cause Analysis”
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “What’s Happening to “I’m Sorry”?”
October 2017 “More Support for Disclosure and Apology”
April 2018 “More Support for Communication and Resolution Programs”
August 13, 2019 “Betsy Lehman Center Report on Medical Error”
September 2019 “Leapfrog’s Never Events Policy”
March 9, 2021 “Update: Disclosure and Apology: How to Do It”
November 2021 “When a Radiologist Recognizes He Committed an Error”
Other very valuable resources on disclosure and apology:
Some of our prior columns on “the second victim”:
References:
Our Serious Incident Response Checklist
NHS (National Health Service UK). Patient Safety Incident Response Framework.
https://www.england.nhs.uk/patient-safety/incident-response-framework/
NHS (National Health Service UK). Serious Incident framework. March 2015
https://www.england.nhs.uk/patient-safety/serious-incident-framework/
Care Quality Commission (UK). Learning, candour and accountability. A review of the way NHS trusts review and investigate the deaths of patients in England. December 2016
https://www.cqc.org.uk/sites/default/files/20161213-learning-candour-accountability-full-report.pdf
NHS (National Health Service UK). Patient Safety Incident Response Framework. Introductory Version. NHS 2020
NHS (National Health Service UK). Introductory version of the PSIRF. NHS 2020
NHS (National Health Service UK). A just culture guide. NHS 2020
https://www.england.nhs.uk/wp-content/uploads/2021/02/NHS_0932_JC_Poster_A3.pdf
NHS (National Health Service UK). Patient safety incident response plan 2020/21. Template
https://www.england.nhs.uk/wp-content/uploads/2020/08/PSIRP_template.docx
Print “NHS Serious Incident Response Framework”
June 7, 2022
SBAR to the Rescue!
Handoffs are among the most common transactions in transitions at all levels of the healthcare system and are also among the processes most prone to error. We know that breakdowns in communication are contributing factors in roughly 70% of all Sentinel Events in Joint Commission’s Sentinel Event database and many of those breakdowns occur during handoffs. The use of structured communications formats has been very helpful in improving handoffs.
Our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and our multiple columns on handoffs (listed below) discussed multiple formats for handoff communications. Some are tailored to the type of handoff. For example, I-PASS has now been widely adopted for physician-to-physician handoffs. Our April 9, 2019 “Handoffs for Every Occasion” discussed formats for a variety of other situational handoffs.
But there is one structured communication tool that has stood the test of time and can be utilized in multiple scenarios – SBAR. The SBAR mnemonic stands for:
SBAR is particularly useful for facilitating communication across professions. For instance, after an RCA showed that a nurse was reluctant (probably for a variety of reasons) to ask a physician to physically come see a patient, we noted that SBAR could have been very helpful:
That communication is succinct, conveys an appropriate amount of urgency, and is actionable.
Murphy and colleagues (Murphy 2022) recently described a quality improvement project to improve communication in one of their ICU’s. In this ICU, there was no standardized communication method used by nurses and advanced practice providers (APP’s). They noted that communication practices differed greatly between the 2 groups, and the nursing and APP staff members had reported communication between the 2 groups multiple times per shift. This often resulted in incomplete, inaccurate, or delayed information when clinical concerns were reported or escalated.
So, they selected SBAR as an appropriate standardized communication tool. Both groups (nursing and APP’s) received education on use of the tool. In addition to a Power Point presentation, other tools were used to reinforce use of SBAR. These included laminated signs near computers and desks, “badge buddies” (mini-versions of the laminated signs), and educational flyers placed in strategic areas.
A total of 200 nurses and 24 APP’s were involved in the project. Surveys before and after the intervention were completed and analyzed. For the APP’s, 62% were using the SBAR tool in clinical practice before and 82% after the intervention, but this did not reach statistical significance. For the nurses, 66% were using the SBAR tool in clinical practice before and 95% after the intervention (p<0.001). Scores on the communication survey subscales of Collaboration, General Perceptions, and Open Communication all improved after the intervention.
Success factors included several informal clinical champions and involvement of nursing leadership, Interestingly, the APP’s role-played clinical scenarios with nurses and provided feedback and encouragement.
After implementation of the SBAR tool, the nurses and APP’s reported a significant increase in their confidence in the accuracy and completeness of data being reported. Though improving teamwork was not a specific goal of this project, both groups also expressed enjoyment in working together, probably also the result of enhanced communication and collaboration between the 2 groups.
Use of the SBAR tool also seemed to spread to communications across other professions. Nurses and APP’s were observed using the SBAR tool with physicians, and respiratory therapists requested SBAR education for their team.
Most physicians appreciate receiving information in a concise, structured format that includes an assessment and recommendations. A few, however, may think such communication may be too assertive. Assertiveness is often a double-edged sword in team situations. Dominating a team can become dangerous but appropriate assertiveness is important. Communication obviously takes place between and among numerous individuals in settings such as the OR. Not being afraid to buck the authority gradient or hierarchy is critical and assertive communication is a key component of good teamwork. One example of escalating assertive communication is the CUSS tool:
C “I’m concerned and need clarification”
U “I am uncomfortable and don’t understand”
S “I’m seriously worried here”
S “Stop”
We highly recommend the SBAR format for inter-professional communications. Use of such a format is helpful not only in hospital venues, but also in outpatient venues. Every organization should do an inventory of the communication formats being used across professions in multiple settings. If no structured one is being used, SBAR is a good option.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The Handback”
December 2014 “I-PASS Passes the Test”
January 6, 2015 “Yet Another Handoff: The Intraoperative Handoff”
March 2017 “Adding Structure to Multidisciplinary Rounds”
August 22, 2017 “OR to ICU Handoff Success”
October 2017 “Joint Commission Sentinel Event Alert on Handoffs”
October 30, 2018 “Interhospital Transfers”
April 9, 2019 “Handoffs for Every Occasion”
November 2019 “I-PASS Delivers Again”
August 2020 “New Twist on Resident Work Hours and Patient Safety”
September 29, 2020 “ISHAPED for Nursing Handoffs”
May 25, 2021 “Yes, Radiologists Have Handoffs, Too”
February 2022 “Communication Failures and Malpractice”
References:
Murphy M, Engel JR, McGugan L, et al. Implementing a Standardized Communication Tool in an Intensive Care Unit. Crit Care Nurse 2022; 42 (3): 56-64
Print “SBAR to the Rescue!”
June 14, 2022
Spinal Tranexamic Acid Again!
We’ve done columns on the devastating consequences of inadvertent spinal injection of tranexamic acid (see our Patient Safety Tips of the Week for June 4, 2019 “Medication Errors in the OR – Part 3” and July 9, 2019 “Spinal Injection of Tranexamic Acid”).
ISMP Canada just issued a safety alert about another such incident (ISMP Canada 2022). (Actually, the error in this incident was identified only when the same error occurred during a subsequent procedure later in the day.) The patient was scheduled for an orthopedic surgical procedure. In the operating room, tranexamic acid was inadvertently injected into the cerebrospinal fluid, instead of the intended local anesthetic bupivacaine. The patient reported extreme pain and demonstrated unusual movements during the procedure, and experienced seizures while in the recovery room. The patient remains bed-bound and is living with extreme chronic pain.
At the time of the incident, both tranexamic acid and bupivacaine were stored in the same drawer of the drug cart. The hospital’s investigation found that a form of confirmation bias (“seeing what you expect to see”) likely contributed even though a double check had been performed. And it was investigation of an open bin of discarded vials (after the second patient was affected) that confirmed that tranexamic acid had been mistakenly administered to the first patient. The ISMP Canada alert does not mention whether barcoding was available in that OR there or not.
In our June 4, 2019 Patient Safety Tip of the Week “Medication Errors in the OR – Part 3” we happened to mention the inadvertent spinal administration of tranexamic acid as one of the medication errors occurring in the OR setting. Tranexamic acid is an antifibrinolytic agent used in the control of traumatic, surgical, and obstetric hemorrhage. In 2015, Patel and Loveridge (Patel 2015) did a review of obstetric neuraxial drug administration errors. That review included four deaths from spinal tranexamic acid administered at caesarean section. At that time, they had four key recommendations to avoid such errors:
Then, in our July 9, 2019 “Spinal Injection of Tranexamic Acid”, we discussed a more recent review by Patel et al. (Patel 2019). They identified 21 reports in the literature of accidental spinal administration of tranexamic acid injected during spinal anesthesia or analgesia. These included seven elective caesarean sections and six patients having orthopedic surgery. Death was reported in 10 patients, and 10 of the remaining 11 patients required intensive care admission for management of refractory convulsions and/or tachyarrhythmias.
Typical symptoms and signs include severe pain in the back, buttocks and legs, myoclonus starting in the legs, generalized convulsions, severe tachycardia and hypertension, and ventricular arrhythmia. In addition, there was usually no sensory or motor block as you’d expect if the intended bupivacaine had been administered.
In almost all cases there was an error related to the ampule containing the tranexamic acid. There was similar size and appearance to the ampules of the intended medication (usually bupivacaine or similar agent). Failure to check the label contributed in many cases. One case involved confusion between the IV line and a spinal catheter that had been inserted for chronic pain management.
Some organizational factors that were reported included a lack of formal drug handling or storage policy, and lack of resources. In three cases, syringes or vials containing tranexamic acid were prepared by personnel other than the practitioner administering spinal anesthesia. On one occasion, the tranexamic acid ampule was stored in the same location as local anesthetics. The ampule was passed unchecked from the assistant to the anesthetist, who also failed to check the ampule.
Patel et al. note that all errors could have been prevented if the recommendations in their 2015 paper had been followed. They also suggest that manufacturers of tranexamic acid should be encouraged to design ampules with recognizable size, shape, fonts and color or, alternatively, tranexamic acid might be manufactured in a vial. The also advise that tranexamic acid, and other non‐anesthetic drugs, should be stored in a separate location in or outside the operating room, to limit the possibility of picking up the wrong drug.
Our previous columns on medication errors in the OR have noted one critical factor contributing to many incidents is that one person (the anesthetist) often orders the medication, prepares it, and administers it. That bypasses the usual chain in the medication administration system in which you have several sets of eyes (physician, pharmacist, and one or more nurses) checking the medication. Double checks would be an obvious potential solution, but a double check failed in the current Canadian case. We don’t see many OR’s in which such double checking actually occurs. Also, barcoding could go a long way to avoid such misadministration. But many OR’s have yet to implement barcoding (see our June 2022 What's New in the Patient Safety World column “Where Are You Barcoding?”).
In an editorial accompanying the 2019 Patel study, Palanisamy and Kinsella (Palanisamy 2019) focus on two important points: (1) reducing the similarity of the ampules and (2) segregating the storage of the drugs. They noted that tranexamic acid and bupivacaine are both patent‐expired drugs that are supplied by a surprising number of generic manufacturers. They stress that ampules of similar size increase the likelihood of mistakes and suggest manufacturers could make ampules distinctive with different colored neck and head rings in addition to the labelling issues. They also stress that facilities should physically segregate tranexamic acid from commonly administered spinal medications. Because tranexamic acid is not frequently administered, it can be housed in a location that is distinct from anesthetic drugs. Note that we (in our June 4, 2019 Patient Safety Tip of the Week “Medication Errors in the OR – Part 3”) and Patel et al. in the above paper have suggested tranexamic acid might be stored outside the OR. But Palanisamy and Kinsella make a plea not to banish tranexamic acid from the labor and delivery ward and operating room. They note tranexamic acid is a safe, inexpensive and modestly effective treatment and that the number needed to treat for IV tranexamic acid to prevent one maternal death from hemorrhage is 267, whereas the number needed to harm for inadvertent administration of tranexamic acid would be much higher.
A NAN (National Alert Network) Alert in 2020 described 3 additional cases of accidental spinal injection of tranexamic acid instead of a local anesthetic intended for regional (spinal) anesthesia (NAN 2020). Container mix-ups were involved in each case. In each case, seizures occurred shortly after the inadvertent spinal injections.
In that NAN alert, ISMP notes that it had previously described 3 such cases (ISMP 2019) and pointed out that the similarity of vials of tranexamic acid to those of the local anesthetics was a key contributing factor. Moreover, these cases are often being performed in areas where barcoding has not been implemented (see our June 2022 What's New in the Patient Safety World column “Where Are You Barcoding?”). And, in some cases, syringe labeling issues may be contributory factors.
Even the orientation at which you store the vials may be important. The NAN alert notes “While label colors and vial sizes are different, the caps on ropivacaine, bupivacaine, and tranexamic acid vials may have the same blue color and could lead staff to select a vial based on cap color, without reading the label, especially if the vials are stored upright with only the caps showing.”
The NAN alert recommended the following prevention measures:
The hospital in the recent Canadian case immediately issued a safety alert, both hospital-wide and province-wide. They suggested the following strategies:
Note that the hospital also began providing tranexamic acid for injection in glass ampules to differentiate it from medications in vials, but acknowledged that there have been case reports of mix-ups between ampules of tranexamic acid and local anesthetics.
ISMP Canada had these further recommendations:
The ISMP Canada alert also has an important point we made in our columns on response to serious incidents – seizing and sequestering any evidence when an adverse incident occurs (see our Patient Safety Tips of the Week for July 24, 2007 “Serious Incident Response Checklist” and May 31, 2022 “NHS Serious Incident Response Framework”). The involved hospital only identified the nature of the error when they found discarded vials of tranexamic acid from the second case. The alert recommends each facility develop a method of disposal in the operating room that enables the review of discarded vials following a critical incident, while ensuring adherence to medical waste disposal policies.
Our June 2022 What's New in the Patient Safety World column “Where Are You Barcoding?”) was basically a plea for all hospitals to extend their barcoding capabilities to areas such as the OR and radiology suites. It is unfathomable that our most powerful medication safety tool is not being used where medications are frequently administered.
And, while we still recommend use of double checks when administering anything spinally, the current Canadian case illustrates that double checks often fail.
A key point we always make is “Don’t store dangerous medications in a location where someone might inadvertently pick it up, prepare it, and administer it”. We learned that lesson many years ago when concentrated potassium chloride was sometimes inadvertently given IV to patients, resulting in fatalities. We also stressed it in our columns (listed below) on the mistaken administration of methylene blue instead of the intended trypan blue in ophthalmology cases. But tranexamic acid is being used more frequently in a variety of procedures, so it may not be practical to eliminate it from most OR or labor and delivery settings. That editorial by Palanisamy and Kinsella (Palanisamy 2019) provides a strong argument against banishing tranexamic acid from the OR or labor and delivery suite. However, hospitals could still do an inventory of use of tranexamic acid in each of their OR’s and selectively remove tranexamic acid from those that almost never use it. For example, an OR that is dedicated to ophthalmology cases might never use it. You could still store tranexamic acid in your labor and delivery rooms and those other OR’s where it is frequently used, while still making sure it is not stored in proximity to your anesthetic drugs.
If your facility uses tranexamic acid, it would be wise to perform a FMEA (failure mode and effects analysis) to identify and mitigate any current vulnerabilities you find.
Some of our prior columns on inadvertent spinal administration of tranexamic acid:
June 4, 2019 “Medication Errors in the OR – Part 3”
July 9, 2019 “Spinal Injection of Tranexamic Acid”
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”
References:
ISMP Canada. ALERT: Substitution Error with Tranexamic Acid during Spinal Anesthesia. ISMP Canada Safety Bulletins 2022; 22(6):
https://ismpcanada.ca/wp-content/uploads/ISMPCSB2022-i6-Tranexamic-Acid-Spinal-Anesthesia.pdf
Patel, S, Loveridge, R. Obstetric neuraxial drug administration errors: a quantitative and qualitative analytical review. Anesthesia and Analgesia 2015; 12: 1570-1577
Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anesthesia 2019; 74(7): 904-914 First Published: April 15, 2019
https://onlinelibrary.wiley.com/doi/abs/10.1111/anae.14662
Palanisamy A, Kinsella SM. Spinal tranexamic acid - a new killer in town. Anaesthesia 2019;74(7): 831-833 Epub April 15, 2019.
https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14632
NAN (National Alert Network) Alerts. Dangerous Wrong-Route Errors with Tranexamic Acid. ISMP 2020; September 9, 2020
https://www.ismp.org/alerts/dangerous-wrong-route-errors-tranexamic-acid
ISMP (Institute for Safe Medication Practices). Dangerous Wrong-Route Errors with Tranexamic Acid—A Major Cause for Concern. ISMP Medication Safety Alert! Acute Care Edition 2019; 24(10): May 23, 2019
https://www.ismp.org/resources/dangerous-wrong-route-errors-tranexamic-acid-major-cause-concern
Print “Spinal Tranexamic Acid Again!”
June 21, 2022
Preventing Post-op Pneumonia
When we discuss hospital-acquired infections (HAI’s) we usually first consider catheter-associated urinary tract infections (CAUTI’s), catheter-associated bloodstream infections (CLABSI’s), and ventilator-associated pneumonias (VAP’s). But nonventilator hospital-acquired pneumonia (NV-HAP) is another frequent HAI that is potentially preventable.
Nonventilator hospital-acquired pneumonia (NV-HAP) is often a complication in patients with stroke or other conditions with impaired swallowing or impaired consciousness. But it is also a frequent post-operative complication.
In our June 2022 What's New in the Patient Safety World column “Guideline Update: Preventing Hospital-Acquired Pneumonia” we discussed the 2022 update of “Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals” (Klompas 2022). That update was collaborative work of the Society for Healthcare Epidemiology (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with input from multiple other organizations and societies.
That update included a new section on prevention of nonventilator hospital-acquired pneumonia (NV-HAP). That section notes there is actually a scant evidence base for strategies to prevent NV-HAP. This section emphasizes oral care, recognizing and managing dysphagia, early mobilization, and implementing multimodal approaches to prevent viral infections. It also notes there is insufficient evidence regarding any recommendations about bed positioning or stress-ulcer prophylaxis and it states that systemic antibiotic prophylaxis is not generally recommended.
Our July 2013 What's New in the Patient Safety World column “I Cough” highlighted a multicomponent intervention bundle that was demonstrated to reduce post-operative pulmonary complications (Cassidy 2013). The “I COUGH” program was associated with a reduction in the incidence of post-op pneumonia from 2.6% to 1.6% and unplanned intubations from 2.0% to 1.2%. The acronym “I COUGH” stands for the components of the intervention bundle use:
I Incentive spirometry
C Coughing and deep breathing
O Oral care (brushing teeth and using mouthwash twice daily)
U Understanding (patient and family education)
G Getting out of bed frequently (at least 3 times daily)
H Head-of-bed elevation
The authors also note that postoperative pain control was a key element of the bundle. The educational piece involved not only patients and families but also physicians and nurses. They developed a standardized order set to incorporate all the key interventions. Unit-specific audit of nursing practice changes probably also played an important role.
The authors also felt that the composition of the workgroup that developed and implemented the program was extremely important. That multidisciplinary workgroup consisted of surgeons, nurses, internal medicine representatives, respiratory therapists, physical therapists, infection control, and quality improvement personnel. They also felt that nurse managers were especially crucial to the success of the program. The catchy acronym ICOUGH also helped staff and patients and families remember the key intervention components.
Sustainability is an issue any time new improvement initiatives are put in place. When intervention bundles are implemented, it is important to assess compliance with both the overall bundle and each element of the bundle. One academic medical center recently introduced a 10-item checklist to help improve compliance with elements of I COUGH (Lamm 2022). The intervention included both provider-driven initiatives (patient oral care, ambulation, frequency of patient being in chair, having incentive spirometer within reach, having information booklet within reach, and the patient’s ability to perform incentive spirometry correctly) as well as patient awareness initiatives (importance of oral care, cough and deep breathing, ambulation, and incentive spirometer use).
The checklist actually consisted of a list of 5 intervention items and templates for how those 5 interventions should be recorded in progress notes:
Postoperative Pneumonia Prevention Checklist
Postoperative Pneumonia Prevention Progress Note:
The medical center had a policy modeled on I COUGH since 2016 but implemented the above checklist in 2020. The research team interviewed 135 postoperative general surgery patients over the study time period, 96 prior to implementation of the checklist, and 39 following implementation.
All the provider compliance measures improved post-implementation: patient receiving/performing oral care twice daily +5.2%, ambulating a minimum of 20 feet at least three times daily +10.2%, being out of bed and in a chair at least twice daily +2.3%, having the incentive spirometer within reach +14.3%, having the ICOUGH explanation booklet in the patient’s room +12.2%, and patient’s ability to perform correct usage of incentive spirometry when prompted by interviewer +9.5%.
Likewise, all patient awareness measures improved after checklist implementation: importance of oral care +1.4%, deep coughing +13.5%, ambulation +20.5%, and incentive spirometer use +7%.
Overall impact on occurrence of post-op pneumonia improved, though it did not reach statistical significance. Using data from the NSQIP database, the rate of post-op pneumonia was 1.97% (31 cases among the 1,577 patients) after the intervention, compared to 2.70% (46 cases among 1,706 patients) in the year before implementation (p=0.104).
The updated guidelines (Klompas 2022) did not specifically deal with post-op patients, but looked at broader studies of oral care in prevention of nonventilator hospital-acquired pneumonia (NV-HAP). They note that before-and-after series suggest a possible benefit but that two large, cluster randomized trials conducted in nursing homes did not show a benefit, though their generalizability to acute-care hospitals is unknown. Also, most randomized trials in acute-care hospitals have focused on ICU patients, most of whom were on mechanical ventilation, making it difficult to discern their effect on NV-HAP. Nevertheless, given little risk of harm, they recommend toothbrushing daily given its benefits for oral health and the possible positive impact on objective outcomes.
They also note that data for early mobilization to prevent NV-HAP among hospitalized patients are sparse. They do cite that a quasi-experimental study of intensified postoperative physical therapy for elderly patients undergoing hip fracture surgery was associated with less pneumonia and shorter length of stay compared to historical controls.
They also note the difficulties in assessing results of implementation of “bundles” to reduce NV-HAP, noting the heterogeneity of the bundles and lack of understanding the impact of individual elements in those bundles.
Elevating the head of the bed is part of the I COUGH protocol. The updated guidelines note that there is insufficient data to determine the impact of this on NV-HAP. They note that elevating the head of the bed is recommended to prevent VAP and VAE despite sparse evidence because some studies suggest benefit, it is simple, economical, and associated with minimal risk of harm in ventilated patients. Even fewer data, however, are available to inform whether and to what extent this applies to NV-HAP.
And the one intervention having the strongest evidence base, diagnosis and management of dysphagia, probably has limited applicability in the typical post-op patient population.
The updated guidelines do provide recommendations for how to implement strategies to reduce ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia. They emphasize that prevention of VAP, VAE, and NV-HAP requires implementing best practices to reduce the risk of infection and nurturing a culture that supports implementation, and that accountability is an essential principle for preventing healthcare-associated infections. The document provides recommendations regarding use of multidisciplinary teams, engagement of local champions, utilization of peer networks, educational sessions, educational materials, standardization of care processes, and measurement of performance. They also stress the importance of creating redundancy, including reminders about best practice and can take the form of posters, bulletins, pens, stamps, pocket cards, 1-page signs, daily goal lists in patient rooms, checklists, and preprinted order sets, text messages, and screensavers on clinical computers.
The updated guidelines also note the importance of engaging family members to assist with preventive care as appropriate and/or to discuss prevention practices with the care
team daily. They note that this provides an external prompt for the performance of best practices and can help increase patient acceptance of practices such as oral care, mobilization, and delirium prevention.
The Lamm study includes details of how they used multiple modalities to educate staff on the checklist initiative and incorporated feedback from reviewers. Importantly, they stressed the rationale for the checklist – that the initial good adoption of I COUGH principles had declined over time.
One important element not discussed in either the updated guidelines or the Lamm study is the role of pain management. This, of course, is a double-edged sword. Adequate pain control improves both coughing/incentive spirometry and early ambulation. But that needs to be balanced against the risks of overmedication of the post-op patient, which can lead to respiratory depression, falls, etc. The original I COUGH study (Cassidy 2013) notes that, while not included in the I COUGH acronym, an important aspect of the program is postoperative pain control.
The Lamm study provides yet another example of the utility of checklists and reminds us that sustainability of quality improvement requires ongoing measurement.
Some of our prior columns on HAI’s (hospital-acquired infections):
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”
February 2015 “17% Fewer HAC’s: Progress or Propaganda?”
April 2016 “HAI’s: Gaming the System?”
September 2016 “More on Preventing HAI’s”
November 2018 “Privacy Curtains Shared Rooms and HAI’s”
December 2018 “HAI Rates Drop”
January 2019 “Oral Decontamination Strategy Fails”
February 2019 “Infection Prevention for Anesthesiologists”
March 2019 “Does Surgical Gowning Technique Matter?”
May 2019 “Focus on Prophylactic Antibiotic Duration”
July 2019 “HAI’s and Nurse Staffing”
February 2020 “NICU: Decolonize the Parents”
June 16, 2020 “Tracking Technologies”
August 2020 “Surgical Site Infections and Laparoscopy”
December 2020 “Do You Have These Infection Control Vulnerabilities?”
May 2021 “CLABSI’s Up in the COVID-19 Era”
August 2021 “Updated Guidelines on C. diff”
October 2021 “HAI’s Increase During COVID-19 Pandemic”
June 2022 “Guideline Update: Preventing Hospital-Acquired Pneumonia”
Some of our prior columns on checklists:
References:
Klompas M, Branson R, Cawcutt K, et al.. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 20: 1-27
Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing Postoperative Pulmonary Complications With a Multidisciplinary Patient Care Program. JAMA Surg 2013; 148(8): 740-745
https://jamanetwork.com/journals/jamasurgery/fullarticle/1693122
Lamm R, MD, Creisher BA, Curran JG, et al. Postoperative Pneumonia Prevention Checklist Improves Provider Compliance and Patient Awareness of Previously Established Reduction Protocol. Patient Safety 2022; 4(2): 62-69
Print “Preventing Post-op Pneumonia”
June 21, 2022
Pneumonia in Nervous System Injuries
Last week we focused on prevention of post-op pneumonia (see our June 21, 2022 Patient Safety Tip of the Week “Preventing Post-op Pneumonia”). But another form of hospital-acquired pneumonia that is even more frequent is that which is seen in patients admitted with a variety of neurological conditions. So, timely is a recent review article on pneumonia in nervous system injuries (Erfani 2022). Pneumonia is a significant contributor to mortality and prolonged lengths of stay in patients with neurological conditions.
Erfani and colleagues conducted an extensive literature search and review on the topic. They note that over a third of patients admitted to neurointensive care units (neuro-ICUs) for a period exceeding 48 hours develop nosocomial infections with pneumonia being the most common type of infection. Ventilator-associated pneumonia is frequent in those patients.
But pneumonia also occurs frequently as a complication in neurological patients not on ventilators or in neuro-ICU’s.
They identify risk factors for hospital-acquired pneumonia (HAP) in general: Glasgow Coma Scale (GCS) less than 8, mechanical ventilation, impaired airway reflexes, supine positioning, aspiration, preexisting diseases like chronic obstructive pulmonary disease (COPD), burns, prolonged ICU stay, use of positive end expiratory pressure (PEEP) during mechanical ventilation, high disease severity, multiple organ dysfunction, older age, prior administration of antibiotics, malnutrition, use of the nasogastric tube, use of paralytic agents, male gender, enteral feeding, immunosuppression, and trauma.
But they note that the nature of the critical conditions in CNS leads to higher susceptibility to developing pneumonia, due to factors such as brain injury-induced immune dysregulation and immunosuppression, high prevalence of dysphagia, and interventions such as placement of external ventricular drains (EVDs).
We have always focused on dysphagia and impairment of consciousness, with consequent aspiration, as the major mechanism for pneumonia in neurological inpatients. However, Erfani and colleagues point out some interesting contributing factors that we had not been aware of. One such contributing factor is brain injury-induced immune dysregulation. That is caused primarily caused by an elevated inflammatory response which leads to central and peripheral production of chemokines, proinflammatory cytokines, and cell adhesion molecules in these patients. Development of the inflammatory response is a crucial part of clearing cellular debris in the CNS following an injury. But chronic and prolonged inflammation response can lead to dysregulation in the immune system. Such is commonly seen in acute events, like trauma, brain surgery, subarachnoid hemorrhage (SAH), or spinal cord injury. When it occurs after stroke, it is named stroke-induced immunodepression syndrome (SIDS). SIDS is considered to be biphasic, the first phase starting as soon as 12 hours after the initial injury with early transient activation lasting up to 24 hours, and a second phase consisting of a systemic immunodepression that can last for several weeks. They also discuss the immunosuppression that may occur due to prolonged catecholamine release which accompanies many of these conditions.
They go on to discuss pneumonia in a variety of neurological conditions.
Known risk factors for stroke-associated pneumonia (SAP) include dysphagia, higher National Institutes of Health Stroke Scale (NIHSS), non-lacunar basal-ganglia infarction, age, large middle cerebral artery (MCA) infarction, multiple hemispheric or vertebrobasilar infarction, mechanical ventilation on admission, and impaired vigilance. The presence of intubation also increases the risk of pneumonia independently of the presence of known aspiration. Conversely, a lower risk of SAP was seen in small-vessel occlusions (We, however, would remind all that bilateral lacunar infarcts, which we often refer to as the “double whammy” syndrome, may lead to pseudobulbar palsy that increases the risk of aspiration). They also note that brain injury-induced immunosuppression may be more common with more massive strokes and strokes impacting certain structures, such as the insular cortex.
They, of course, do go on to discuss dysphagia and impaired consciousness as major factors contributing to development of pneumonia after stroke.
In terms of pneumonia prevention, they do stress that addressing dysphagia is one of the most important interventions. It is critical that, in patients with stroke or the other mentioned neurological conditions, that an assessment of swallowing be performed prior to giving food or anything via mouth. Improved screening for dysphagia and nurse education has been shown to decrease the risk of pneumonia as was demonstrated in a single-center study which showed a decrease in pneumonia prevalence from 6.5% to 2.8% after the screening and education changes were implemented.
Early administration of prophylactic antibiotics has not been shown to be effective in decreasing mortality or functional outcome in these patients and is not indicated. They also note that oropharyngeal decontamination with povidone-iodine has not been effective in the prevention of ventilator-associated pneumonia (VAP) in patients with critical brain injuries or cerebral hemorrhages.
.
The timing of tracheostomy placement in such patients who require continuous ventilation does not seem to affect the mortality rate but, in some studies, early tracheostomy placement may decrease the duration of ventilation. (Note that a just-published study (Bösel 2022) on the effect of early vs standard approach to tracheostomy among patients with severe stroke receiving mechanical ventilation showed no difference in the rate of survival without severe disability at 6 months. In that study, pneumonia within 48 hours of tracheostomy was more frequent in the early tracheostomy group but that did not reach statistical significance. There were no significant differences in the total duration of mechanical ventilation or ICU length of stay.)
Erfani and colleagues also discuss another potential prevention strategy: addressing brain injury-induced immunosuppression. Since this immunosuppression is mainly due to sympathetic nervous system activation, they discuss the potential use of β-adrenergic receptor blockers but caution that further assessment of β-blocker administration needs to be carried out in order for it to be confirmed as a routine choice for the prevention of pneumonia in NICU’s.
In our June 2022 What's New in the Patient Safety World column “Guideline Update: Preventing Hospital-Acquired Pneumonia” we discussed the 2022 update of “Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals” (Klompas 2022). That update was collaborative work of the Society for Healthcare Epidemiology (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with input from multiple other organizations and societies.
That update included a new section on prevention of nonventilator hospital-acquired pneumonia (NV-HAP). That section notes there is actually a scant evidence base for strategies to prevent NV-HAP. This section emphasizes oral care, recognizing and managing dysphagia, early mobilization, and implementing multimodal approaches to prevent viral infections. Regarding diagnosis and management of dysphagia, the updated guideline had the following recommendations:
One surprising omission from the discussion of pneumonia in neurological conditions is OSA (obstructive sleep apnea). We know that OSA is common in acute stroke patients and some of the other conditions, and that OSA has been linked as a possible contributing factor to community-acquired pneumonia (Chiner 2016). It would certainly be of interest to see if OSA is a risk factor for development of pneumonia in these and other inpatient conditions.
For those that are interested, the Erfani review also discusses pneumonia is subarachnoid hemorrhage, brain traumatic injury, intracerebral hemorrhage, spinal cord injury, status epilepticus, neuromuscular diseases, and multiple sclerosis (MS) and demyelinating diseases. It also has sections on radiographic findings and treatment of pneumonia. The Erfani review has 139 references with links. We think you will find this very useful.
References:
Erfani Z, Jelodari Mamaghani H, Rawling J, et al. Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations. Cureus 2022; 14(6): e25616
Bösel J, Niesen W, Salih F, et al. Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial. JAMA 2022; 327(19): 1899-1909
https://jamanetwork.com/journals/jama/article-abstract/2792016
Klompas M, Branson R, Cawcutt K, et al.. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 20: 1-27
Chiner E, Llombart M, Valls J, et al. Association between Obstructive Sleep Apnea and Community-Acquired Pneumonia. PloS One 2016; 11(4): e0152749
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822965/
Print “Pneumonia in Nervous System Injuries”
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
Click on the "Contact Us" button at the left to send us your comments on our "Patient Safety Tip of the Week" cases.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
September 27, 2022
September 20, 2022
September 13, 2022
Smart Socks and Robots for Fall Prevention?
September 6, 2022
AORN and Others on Retained Surgical Items
August 30, 2022
August 23, 2022
Yes, There is a Proper Way to Assess Orthostatic Hypotension
August 16, 2022
August 9, 2022
Tip of the Week on Vacation
August 2, 2022
Tip of the Week on Vacation
July 26, 2022
More Risks in the Radiology Suite
July 19, 2022
Sucked Out of the Plane at 17,000 Feet
July 12, 2022
Radiologists Racked by Interruptions
July 5, 2022
Tip of the Week on Vacation
June 28, 2022
Pneumonia in Nervous System Injuries
June 21, 2022
June 14, 2022
June 7, 2022
May 31, 2022
NHS Serious Incident Response Framework
May 24, 2022
Requiring Indication for Antibiotic Prescribing
May 17, 2022
Patient Harm in Medicare Inpatients
May 10, 2022
May 3, 2022
April 26, 2022
Challenges with Early Warning Systems
April 19, 2022
April 12, 2022
A Healthcare Worker’s Worst Fear
April 5, 2022
Follow-up on Incidental Findings
March 29, 2022
Disturbing Stats on Perioperative Benzodiazepine Use in Elderly Patients
March 22, 2022
Not Just Politicians That Behave Badly
March 15, 2022
Medication Errors in Home Care
March 8, 2022
Update on Retained Surgical Items
March 1, 2022
Including the Indication on Prescriptions
February 22, 2022
Medication Reconciliation at ICU Exit
February 15, 2022
February 8, 2022
ED to Inpatient Delays Increase Mortality
February 1, 2022
Perioperative Delirium is Not Just Postoperative
January 25, 2022
More on Dental Patient Safety Issues
January 18, 2022
January 11, 2022
Documenting Distractions in the OR
January 4, 2022
Spin or Not: A Useful Secondary Finding in a Study
December 28, 2021
Tip of the Week on Vacation
December 21, 2021
December 14, 2021
Delayed Hemorrhage After Head Trauma in Anticoagulated Patients
December 7, 2021
November 30, 2021
November 23, 2021
The Perils of Hypertonic Sodium Chloride
November 16, 2021
Cognitive Biases and Heuristics in the Delivery Room
November 9, 2021
November 2, 2021
Adverse Drug Events After Hospitalization
October 26, 2021
Opioid-Induced Respiratory Depression Costly in Fiscal as Well as Human Terms
October 19, 2021
COVID-19 Vaccine/ Flu Vaccine Mixups
October 12, 2021
FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?
October 5, 2021
September 28, 2021
Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
September 14, 2021
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
August 31, 2021
The Community Pharmacy and Patient Safety
August 24, 2021
More Home Infusion Safety Issues
August 17, 2021
Tip of the Week on Vacation
August 10, 2021
Tip of the Week on Vacation
August 3, 2021
Obstetric Patients More At-Risk for Wrong Patient Orders
July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
Copyright 2012 The Truax Group Healthcare Consulting Patient Safety Solutions Tools Tips & Resources. All rights reserved.
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax