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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
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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
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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
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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
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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
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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
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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
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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
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December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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