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April 3, 2018
Cost of a CAUTI
Some of our earliest columns on the cost of complications (see our Patient Safety Tips of the Week for August 21, 2007 “Costly Complications About to Become Costlier” and January 22, 2008 “More on the Cost of Complications”) noted wide variation in the “attributable” costs of CAUTI’s (catheter-associated urinary tract infections).
A new systematic review emphasizes that the attributable costs of CAUTI’s are very dependent upon the nature of the patient population and location of services (Hollenbeak 2018). From that review the authors note the attributable costs of a CAUTI were: $876 (inpatient cost to the hospital for additional diagnostic tests and medications); $1,764 (inpatient cost to Medicare for non-intensive care unit [ICU] patients); $7,670 (inpatient and outpatient costs to Medicare); $8,398 (inpatient cost to the hospital for pediatric patients); and $10,197 (inpatient cost to Medicare for ICU patients).
That review is timely since there were also recent studies on CAUTI’s in the latter two circumstances (ICU’s and pediatric populations).
Mullin and colleagues (Mullin 2017) assembled a project team composed of all critical care disciplines to address an institutional goal of decreasing CAUTI’s. Interventions implemented between year 1 and year 2 included protocols recommended by the CDC for placement, maintenance, and removal of catheters. Also, leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Following implementation, the CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. Device utilization ratio was 0.7 in 2013 and 0.68 in 2014. Hospital-acquired bloodstream infection rates per 1,000 patient days also decreased from 2.8 in 2013 to 2.4 in 2014. The authors attributed success to the multifaceted and collaborative approach but also singled out stewardship of culturing as a key component of their success.
The role of cranberry products in prevention or treatment of urinary tract infections has been controversial, with some studies showing benefit and others showing no benefit. But one study in a heterogeneous ICU population (Sorour 2016) showed that the addition of cranberry-containing products and antimicrobial meatal care may further reduce incidence of CAUTI when added to standard recommendations.
A previous study showed that implementation of a quality improvement prevention bundle can significantly reduce CAUTI rates in children (Davis 2014). The four elements in their prevention bundle were:
Implementation was associated with a 50% reduction in the mean monthly CAUTI rate, from 5.41 to 2.49 per 1000 catheter-days. Most patients with CAUTIs were female (75%), received care in the pediatric or cardiac ICUs (70%), and had at least 1 complex chronic condition (98%). Nearly 90% of patients who developed a CAUTI had a recognized indication for initial catheter placement.
But, of course, CAUTI’s are a concern not just in ICU populations but also non-ICU populations. One other intervention merits noting since it uses one of our favorite tools, the “huddle” (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare”). A recent Health Leaders Media article (O’Brien 2018) highlighted work done at St. Anthony Hospital in Chicago. They used a daily interdisciplinary safety huddle (DISH) to focus on central venous catheters and indwelling urinary catheters. Their DISH huddle is “a 15-minute meeting held in the morning to incorporate participation from a swath of hospital employees ranging from security to nurse managers, emergency services, and infection control”. They also instituted a policy for nurse managers to report catheter usage, while an infection control practitioner reviewed indications, duration, and plans for device removal. Any barriers to catheter removal were required to be addressed within 24 hours. After DISH was implemented, they had a significant decrease in central venous and indwelling urinary catheter use in non-ICU settings. They attributed these declining device utilization rates as key to a 90% reduction in HAI’s, which resulted in a cost savings of nearly $500,000.
The Hollenbeak study did not address the cost of CAUTI’s in the other setting where CAUTI’s remain significant - long-term care (LTC). But it’s worth noting the “AHRQ Toolkit Designed to Reduce Urinary Tract Infections in Long-Term Care” (AHRQ 2017). The toolkit is based on the experiences of more than 450 long-term care facilities across the country that participated in an AHRQ-funded project and reported significant CAUTI rate reductions. The toolkit uses strategies from AHRQ's Comprehensive Unit-based Safety Program (CUSP) and includes behavior change elements that promote leadership involvement, improvement in safety culture, teamwork, and communication, and sustainability.
Our other columns on urinary catheter-associated UTI’s:
References:
Hollenbeak CS, Schilling AL. The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review. Am J Infect Control 2018; Published online: February 22, 2018
http://www.ajicjournal.org/article/S0196-6553(18)30036-1/fulltext
Mullin KM, Kovacs CS, Fatica C, et al. A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract Infections in the Intensive Care Unit with an Emphasis on “Stewardship of Culturing”. Infect Control Hosp Epidemiol 2017; 38(2): 186-188
Sorour K, Nuzzo E, Tuttle M, et al. Addition of bacitracin and cranberry to standard Foley care reduces catheter-associated urinary tract infections. Canadian Journal of Infection Control 2016; 31(3): 166-168 Fall 2016
http://ipac-canada.org/photos/custom/CJIC/Vol31no3.pdf
Davis KF, Colebaugh AM, Eithun BL, et al. Reducing Catheter-Associated Urinary Tract Infections: A Quality-Improvement Initiative. Pediatrics 2014; published online August 11, 2014
http://pediatrics.aappublications.org/content/early/2014/08/06/peds.2013-3470
O’Brien J. Fewer Catheters, Fewer Infections: Reducing HAIs Through a 'Hospital-wide Huddle'. Health Leaders Media 2018; February 19, 2018
AHRQ (Agency for Healthcare Research and Quality). Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities. AHRQ March 2017
Print “Cost of a CAUTI”
April 10, 2018
Prepping the Geriatric Patient for Surgery
In our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” we proposed that the three most important considerations during the preoperative assessment of geriatric patients are: (1) assessment for frailty (2) assessment for delirium risk and (3) risk assessment for obstructive sleep apnea. We’ve now done numerous columns on the impact of frailty on surgical outcomes, complications, and mortality (see full list below). But since our last column (May 16, 2017 Patient Safety Tip of the Week “Are Surgeons Finally Ready to Screen for Frailty?”) there have been innumerable studies on the relationship between frailty and surgery and some good recommendations regarding preparation of geriatric patients for surgery.
A systematic review and meta-analysis (Watt 2018) looking for prognostic factors for postoperative complications in elderly patients undergoing surgery had some interesting findings. Frailty, cognitive impairment, depressive symptoms, and smoking were associated with developing postoperative complications, but age and ASA status were not. We have often emphasized that age, per se, is not a good predictor of complications. Rather, it is the underlying functional status of the individual that is important, independent of chronological age. The authors recommend focusing on potentially modifiable prognostic factors (e.g., frailty, depressive symptoms, and smoking) associated with developing postoperative complications that can be targeted preoperatively to optimize care.
The Watt study and others have aptly pointed out that pre-existing cognitive impairment is a risk factor for postoperative delirium and other complications. We’ve noted in prior columns on delirium that simple assessment of cognitive function can be done using the MMSE (Mini Mental Status Exam) or the MiniCog, or simply having the patient draw a clock.
Two widely used tools to estimate surgical risk, the ASA status and the ACS NSQIP Surgical Risk Calculator, do not include either frailty or cognitive impairment in their risk assessments. The ACS NSQIP Surgical Risk Calculator is a nationally validated tool and does have an input for functional status (independent, partially dependent, fully dependent). But given all the recent attention to both frailty and cognitive impairment as factors contributing to surgical risk, we suspect future updates of the NSQIP online calculator will include modifications for these factors.
The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. Culley et al. (Culley 2017) studied 211 patients 65 year of age or older without a diagnosis of dementia who were scheduled for an elective hip or knee replacement, screening them preoperatively using the Mini-Cog. Patients with a Mini-Cog score less than or equal to 2 (24% of patients) were more likely to be discharged to a place other than home, develop postoperative delirium, and have a longer hospital length of stay.
Frailty and cognitive impairment are often associated. A previous study noted the close association between frailty and cognitive impairment and found that taking cognitive function into account may allow better prediction of adverse outcomes of frailty in later life (Lee 2017a). Now a new study (Makhani 2017) demonstrated that using a combination of the Fried Frailty score and the Emory clock draw test to assess preoperative frailty and cognitive impairment, respectively, more accurately predicted survival after surgery than either alone. The authors conclude that the addition of cognitive assessment to physical frailty measure can improve preoperative decision making and possibly early intervention, as well as more accurate patient counseling.
A second recent study (Min 2017) used the Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA) tool, along with the Mini-Cog and Timed Up and Go test during preoperative evaluation of patients 70 years of age or older who were underwent elective surgery. Patients were assessed on 5 preoperative activities of daily living recommended by the American College of Surgeons (bathing, transferring, dressing, shopping, and meals), history of falling or gait impairment, and depressive symptoms (2-item Patient Health Questionnaire). Patients also underwent a brief cognitive examination (Mini-Cog) and gait and balance assessment (Timed Up and Go test). A novel question was also asked as to whether patients expected they could manage themselves alone after discharge. Comorbidities and work-related relative value units (categorized into low, moderate, and high tertiles) were also collected.
A total of 131 of 740 patients had geriatric complications, and 114 of 740 patients had surgical complications; 187 of 740 patients (25.3%) had either geriatric or surgical complications. The following items were independently associated with postoperative complications: the number of difficulties with activities of daily living, anticipated difficulty with postoperative self-care, Charlson Comorbidity score of 2 or more vs less than 2, male sex, and work-related relative value units. A whole-point VESPA score used alone to estimate risk of complications also demonstrated excellent fit.
Yet another recent study assessed the impact of frailty on failure to rescue in a cohort of almost a million patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program (Shah 2018). Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score, ≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). They found that frailty has a dose-response association with complications and failure to rescue and that this relationship is apparent after low-risk and high-risk inpatient surgery.
Most studies on “the elderly” include all patients age 65 and older. But one study (Pelavski 2017) points out that “the eldest old” (those age 85 and older) is the fastest-growing and most vulnerable group and also an insufficiently studied group. Those researchers looked at patients aged ≥85 years undergoing any elective procedure and analyzed demographic data, grade of surgical complexity, preoperative comorbidities, and some characteristically geriatric conditions (functional reserve, nutrition, cognitive status, polypharmacy, dependency, and frailty). The 30-day mortality was 7.9% and had 3 predictors: malnutrition (odds ratio 15), complexity 3 (OR 9.1), and osteoporosis/osteoporotic fractures (OR 14.7). Significant predictors for morbidity were ischemic heart disease (OR 3.9) and complexity 3 (OR 3.6), while a nonfrail phenotype (OR 0.3) was found to be protective. Only 2 factors were found to be predictive of longer admissions, namely complexity 3 (OR, 4.4) and frailty (OR 2.7). Finally, risk factors for escalation of care in living conditions were slow gait (a surrogate for frailty, OR 2.5), complexity 3 (OR 3.2), and hypertension (OR 2.9). They conclude that surgical complexity and certain geriatric variables (malnutrition and frailty), which are overlooked in American Society of Anesthesiologists and most other usual scores, are particularly relevant in this population.
Estimating the risk of morbidity and mortality for surgery is important in providing patients with solid information when discussing whether to proceed with surgery. It can lead to realistic expectations. But accurate prediction might also help avoid decisions to unnecessarily avoid surgery. In fact, a recent study showed that both surgical and internal medicine residents routinely overestimate the risk of postoperative complications and death compared to the NSQIP online calculator (Healy 2017). Maybe the residents are already considering factors not included in the NSQIP, such as frailty and cognitive impairment!
Another important concept in geriatric care is “functional trajectory”. That basically describes the course of disabilities in a patient. Researchers at Yale (Stabenau 2018) logically hypothesized that the functional trajectory of a patient in the year prior to surgery might predict functional outcomes after surgery. They studied community-living persons, 70 years or older for the year prior to and year after surgery. Before surgery, 4 functional trajectories were identified: no disability, mild, moderate, and severe disability. After surgery, 4 functional trajectories were identified: rapid, gradual, partial, and little improvement. They saw rapid improvement in 51.7% of participants with no disability before surgery, but only 9.5% of those with mild disability, and 0% in those in the moderate and severe trajectory groups. For participants with mild to moderate disability before surgery, gradual improvement was seen in 54.8% and partial improvement in 49.3%. Most participants (81.8%) with severe disability before surgery exhibited little improvement. Also, outcomes were better for participants undergoing elective versus nonelective surgery. Thus, functional prognosis in the year after major surgery is highly dependent on premorbid function and functional trajectory.
How are we actually doing at documenting issues related to frailty in patients undergoing surgery? A study done in Ottawa, Ontario (MacDonald 2017 abstract 1473) found striking gaps between recommended and actual practices for elderly patients undergoing non-cardiac surgery. The authors noted that, for geriatric patients, guidelines recommend assessment for frailty, decision-making capacity (DMC), and the consent process be documented in a manner that reflects geriatric syndromes such as frailty and cognitive dysfunction. A random sample of 240 patients, aged 65 or older, having elective inpatient surgery at a tertiary care center was identified.
Frailty was mentioned in 1% of the charts reviewed and no formal frailty assessments were documented. Risk quantification was documented in 15% of the preoperative notes. The four legally relevant criteria for assessment of DMC were documented in 3%
of the notes. All notes documented at least four of the seven elements required for informed consent but all elements were present in only 1% of the notes. Specific risks of the procedure were documented in 56%, unique risks in 20%, and the risks of not treating the diagnosed condition were documented in 6% of surgical notes.
The authors conclude that, despite guidelines for optimal preoperative assessment of the geriatric patient, recommended practices such as frailty and DMC assessment are rarely documented. Furthermore, legally required elements of informed consent are regularly missing from the preoperative surgical notes.
There are, of course, a variety of tools used for screening for frailty, varying from simple to complex. Many are described in our May 31, 2016 Patient Safety Tip of the Week “More Frailty Measures That Predict Surgical Outcomes” and the other columns listed at the end of today’s column. We’ve noted some of the simpler ones have looked at gait speed, the timed up-and-go test, handgrip strength, and others. And in our May 16, 2017 Patient Safety Tip of the Week “Are Surgeons Finally Ready to Screen for Frailty?” we noted a stoudy that looked at individual components of the Fried frailty phenotype measures (gait speed, hand-grip strength as measured by a dynamometer, and self-reported exhaustion, low physical activity, and unintended weight loss) in a primary care setting (Lee 2017b). The researchers found that individual criteria all showed sensitivity and specificity of more than 80%, with the exception of weight loss. The positive predictive value of the single-item criteria in predicting the Fried frailty phenotype ranged from 12.5% to 52.5%. When gait speed and hand-grip strength were combined as a dual measure, the positive predictive value increased to 87.5%. They conclude that, while use of gait speed or grip strength alone was found to be sensitive and specific as a proxy for the Fried frailty phenotype, use of both measures together was found to be accurate, precise, specific, and more sensitive than other possible combinations and that assessing both measures is feasible within the primary care setting.
Recently, Canadian researchers performed a multicenter cohort study to compare the predictive accuracy of two leading frailty tools, the Clinical Frailty Scale (CFS) and the Modified Fried Index (mFI), in identifying older patients who have self-reported disability after elective surgery (McIsaac 2017 abstract 284220). The primary outcome was new disability at 90 days after surgery using the validated WHODAS 2.0 tool. Preliminary findings showed new disabilities were present in 11.2 % of 509 participants. The CFS was 77% sensitive and 54% specific for new disability; the mFI 13% and 84% respectively. The relative true positive rate (rTPR) and relative false positive rate (rFPR) were 5.92 and 2.9 (CFS vs. mFI). Each unit increase on the CFS was associated with a 1.71 times increase in the odds of new disability; each increase in the mFI increased the odds 1.64-fold. Thus, these preliminary results suggest that the CFS was more sensitive at identifying patients who experience a new disability after surgery, while the mFI was more specific. The incremental risk associated with increasing frailty on each scale was similar. Based on these results, the authors recommend that choice of a frailty instrument be guided by the purpose for screening. Where a sensitive approach is needed, the CFS appears to be superior. When specificity is required, the mFI appears to be superior. Efforts to assess the feasibility and acceptability of each instrument are needed, as are evaluation of optimal cut-points in the perioperative setting.
But we concur with the authors that ease of and time required for administration of the tool will likely be a deciding factor in which to use. We have often advocated for use of the most simple tests for frailty (timed up and go test, gait speed, handgrip strength) to get surgeons to screen for frailty preoperatively. But McIsaac and colleagues note that the Clinical Frailty Scale takes only about 30 seconds to administer, compared to about 5 minutes for the modified Fried Index. You can see the Clinical Frailty Scale here.
Another recent Canadian study used the Clinical Frailty Scale to prospectively evaluate patients 65 years of age or older who underwent emergency abdominal surgery (Li 2018). 54.5% were classified as vulnerable (CFS score 3 or 4) and 22.1% as frail (CFS score 5 or 6). At 30 days after discharge, the proportions of patients who were readmitted or had died were greater among vulnerable patients (adjusted odds ratio 4.60), and frail patients (adjusted OR 4.51). And by 6 months, the degree of frailty independently and dose-dependently predicted readmission or death. Thus, the degree of frailty has important prognostic value for readmission. Yet only 4.2% of those classified as vulnerable or frail received a geriatric consultation.
The bottom line: screening for frailty and cognitive decline need not be time consuming and can be easily performed in an office or clinic setting prior to anticipated surgery using either one of the formal frailty scores or one of the simple tests noted above. Patients identified as frail by these methods not only need closer surveillance for complications post-operatively but may benefit from a multidisciplinary comprehensive geriatric management program prior to surgery.
Feldman and Carli (Feldman 2018), in an editorial accompanying the Shah study, point out that the evidence associating frailty with poor outcomes is now firmly established and that the real question is whether we can intervene to optimize patients prior to surgery and thereby improve outcomes.
So, are preoperative programs for frail elderly patients successful? Recently published results of the Perioperative Optimization of Senior Health (POSH) study (McDonald 2018) would suggest they are. POSH looked patients who were undergoing elective abdominal surgery and were considered at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, polypharmacy, visual or hearing loss, or simply deemed by their surgeons to be at higher risk). Intervention patients received a multidisciplinary comprehensive preoperative evaluation that focused on cognition, medications, comorbidities, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Despite higher mean age and morbidity burden, older adults who participated in this interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group. Though this was not a randomized, controlled trial (it was a before/after study design) and did not include a formal frailty measure, it is quite clear that most or all the intervention group patients were frail.
One small randomized trial of “prehabilitation” in high-risk patients (age >70 years and/or American Society of Anesthesiologists score III/IV) undergoing elective major abdominal surgery has recently been completed (Barberan-Garcia 2018).The researchers randomized 71 patients to the control arm and 73 to intervention. Prehabilitation covered 3 actions: motivational interview; high-intensity endurance training, and promotion of physical activity. The intervention group enhanced aerobic capacity, reduced the number of patients with postoperative complications by 51%, and the rate of complications (P = 0.001).
But a larger randomized study is ongoing. After doing a systematic review (McIsaac 2017 abstract 1037) that concluded there were few studies evaluating interventions specific to frail surgical patients, Canadian researchers began a study to test the efficacy of home-based prehabilitation of frail older people to improve their postoperative function following elective surgery cancer surgery (McIsaac 2017 abstract 1256). The study is randomizing consenting patients >65 years who are scheduled to undergo elective surgery for intraabdominal/thoracic cancer ≥4 weeks from recruitment, and who are diagnosed with frailty based on a Clinical Frailty Scale score of >4 out of 9. Patients in the intervention group will perform a home-based total-body exercise training program (prehabilitation) based on a protocol of proven efficacy. This prehabilitation consists of 3 components: 1) strength; 2) aerobics; and 3) flexibility. Participants also receive in-person teaching and video instruction to facilitate the program at home. Compliance will be assessed by weekly phone calls. Control group participants receive standard care. Primary outcome is the 6-minute walk test at the first clinic follow up after hospital discharge. Secondary outcomes are the Short Physical Performance Battery, EQ-5D health related quality of life measure, disability-free survival, adverse events, length of stay, and disposition,
Hopefully the ongoing McIsaac study will answer the question about utility of prehabilitation in preparing the frail geriatric patient for surgery.
Most of the published work on the association between frailty and surgical morbidity and mortality has pertained to surgical procedures traditionally performed on inpatients. But a recent study looked at ambulatory general surgery procedures (Seib 2018). Seib and colleagues found that frailty was associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications.
So while we are waiting for the above study results, what should you do? Coburn et al. (Colburn 2017) were able to distill the recommendations of the 60+ pages in the Optimal Perioperative Management Of The Geriatric Patient: Best Practices Guideline from ACS NSQIP®/American Geriatrics Society (Mohanty 2016) into a much more concise document. It includes most of the interventions done in the POSH study noted above. This contains a nice checklist of items for clinicians to consider in preparing geriatric patients for surgery. In addition to traditional surgical risk factors like cardiac and pulmonary risks, it focuses on risk of developing delirium, risk of frailty, and risk of functional decline. In addition to surgical risk, it has categories for medication management, functional status, goals of care, and care transitions.
It also has a section on in-hospital perioperative management that includes a table with drugs that should be avoided and alternatives that may be used. It also includes good advice regarding anesthesia, analgesia, perioperative nausea/vomiting (PONV), and fluid management. It has an excellent section on prevention, assessment, and management of postoperative delirium.
It discusses prevention of pulmonary complications, UTI’s, falls, pressure ulcers, and nutritional issues. There is a very good section on strategies to prevent functional decline (use of the Hospital Elder Life Program, early mobilization, early involvement of PT/OT, geriatric co-management, and interdisciplinary discharge planning).
It then focuses on the importance of care transition planning, assessing social support and need for home health before discharge, and involvement of family and caregivers as appropriate in discharge planning. Good medication reconciliation is stressed, including ensuring the patient and/or caregiver understand the purpose of each drug, how to take, and expected side effects/adverse reactions. The discharge planning process needs to be interdisciplinary, including surgeons, geriatricians, nursing and pharmacy plus social workers/discharge planners and family/caregivers. We’re glad to see they emphasize the importance of communicating with the patient’s primary caregiver and ensuring that a complete discharge summary is provided for the PCP. Also, as we’ve so often stressed, documentation of pending labs/studies, needs to be communicated to the patient, his/her PCP, and the surgeon.
There are numerous existing standards of care for the geriatric patient undergoing surgery. The Coalition for Quality in Geriatric Surgery (CQGS) includes 58 diverse stakeholder organizations committed to improving geriatric surgery. Using a modified RAND-UCLA Appropriateness Methodology, CQGS found that three hundred six of 308 (99%) standards to improve the surgical care of older adults were rated as valid to improve quality of geriatric surgery (Berian 2018). We refer you to the Berian article to see all 306 standards.
The AORN Position Statement on Care of the Older Adult in Perioperative Settings (AORN 2015) also includes important considerations for the nursing approach to older patients in the perioperative period.
As our population continues to age, more and more elderly patients will be undergoing surgery. We need to have in place systems that are attuned to the unique risks that this population presents.
Some of our prior columns on preoperative assessment and frailty:
References:
Watt J, Tricco AC, Talbot-Hamon C, et al. Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis. BMC Med 2018; 16: 2
https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0986-2
ACS NSQIP Surgical Risk Calculator
https://riskcalculator.facs.org/RiskCalculator/
Culley DJ, Flaherty D, Fahey MC, et al. Poor Performance on a Preoperative Cognitive Screening Test Predicts Postoperative Complications in Older Orthopedic Surgical Patients. Anesthesiology 2017; 127(5): 765-774
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2654245
Lee L, Patel T, Costa A, Bryce E, Hillier LM, Slonim K, et al. Screening for frailty in primary care. Accuracy of gait speed and hand-grip strength. Can Fam Physician 2017; 63: e51-7
http://www.cfp.ca/content/63/1/e51
Makhani SS, Kim FY, Li Y, et al. Cognitive Impairment and Overall Survival in Frail Surgical Patients. J Amer Coll Surg 2017; published online August 4, 2017
http://www.journalacs.org/article/S1072-7515(17)31705-2/fulltext
Min L, Hall K, Finlayson E, et al. Estimating Risk of Postsurgical General and Geriatric Complications Using the VESPA Preoperative Tool. JAMA Surg 2017; Published online August 2, 2017
http://jamanetwork.com/journals/jamasurgery/article-abstract/2644903
Min L, Hall K, Finlayson E, et al. The Vespa Pre-Operative Tool: A Scale That Predicts Post-Surgical General And Geriatric Complications. Innovation in Aging 2017; 1(suppl_1): 928 Published: 30 June 2017
https://academic.oup.com/innovateage/article/1/suppl_1/928/3900410
Shah R, Attwood K, Arya S, et al. Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery. JAMA Surg 2018; Published online March 21, 2018
Pelavski AD, De Miguel M, Alcaraz Garcia-Tejedor G, et al. Mortality, Geriatric, and Nongeriatric Surgical Risk Factors Among the Eldest Old: A Prospective Observational Study. Anesthesia & Analgesia 2017; 125(4): 1329-1336
Healy JM, Davis KA, Pei KY. Comparison of Internal Medicine and General Surgery Residents' Assessments of Risk of Postsurgical Complications in Surgically Complex.Patients. JAMA Surg 2017; Published online October 11, 2017
https://jamanetwork.com/journals/jamasurgery/fullarticle/2656839
Stabenau HF, Becher RD, Gahbauer EA, et al. Functional Trajectories Before and After Major Surgery in Older Adults, Annals of Surgery 2018; Published Ahead of Print: January 19, 2018
MacDonald DB, Pelipeychenko D, Boland L, McIsaac DI. Documentation of Frailty, Capacity and Consent for Elderly Patients Having Elective Inpatient Non-Cardiac Surgery: A Clear Evidence-Practice Gap. International Anesthesia Research Society 2017 Annual Meeting. Abstract 1473
https://iars.app.box.com/v/IARS2017AbstractSupplement/file/164641914799
Lee Y, Kim J, Chon D, et al. The effects of frailty and cognitive impairment on 3-year mortality in older adults. Maturitas 2017; 107: 50-55
http://www.maturitas.org/article/S0378-5122(17)30711-9/fulltext
McIsaac DI, Hamilton G, Hladkowicz E, Bryson G. Comparing Two Frailty Tools To Predict Disability After Elective Noncardiac Surgery: A Multicentre Cohort Study. 2017 annual meeting of the Canadian Anesthesiologists’ Society (abstract 284220)
http://www.casconference.ca/cas-media/2017/abstracts/CAS_2017_Poster_Discussions.pdf
Clinical Frailty Scale
http://camapcanada.ca/Frailtyscale.pdf
Li Y, Pederson JL, Churchill TA, et al. Vulnerable Populations: Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study. CMAJ 2018; 190 (7): E184-E190
http://www.cmaj.ca/content/190/7/E184
Feldman LS, Carli F. From Preoperative Assessment to Preoperative Optimization of Frailty. (editorial). JAMA Surg 2018; Published online March 21, 2018
https://jamanetwork.com/journals/jamasurgery/article-abstract/2675990?redirect=true
McDonald SR, Heflin MT, Whitson HE, et al. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older AdultsThe Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg 2018; Published online January 3, 2018
https://jamanetwork.com/journals/jamasurgery/article-abstract/2666836?redirect=true
Barberan-Garcia A, Ubré M, Roca J, et al. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. Ann Surg 2018; 267(1): 50-56
https://insights.ovid.com/pubmed?pmid=28489682
McIsaac DI, Ting Han Jen T, Mookerji N, et al. Prehabilitation Before Cancer Surgery to Improve Patient Function in Frail Elderly. International Anesthesia Research Society 2017 Annual Meeting. Abstract 1037
https://iars.app.box.com/v/IARS2017AbstractSupplement/file/164641914799
McIsaac DI, Moloo H, Lavallee LT, et al. Prehabilitation Before Cancer Surgery to Improve Patient Function in Frail Elderly. International Anesthesia Research Society 2017 Annual Meeting. Abstract 1256
https://iars.app.box.com/v/IARS2017AbstractSupplement/file/164641914799
Seib CD, Rochefort H, Chomsky-Higgins K, et al. Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations. JAMA Surg 2018; 153(2): 160-168 Published online October 11, 2017
Colburn JL, Mohanty S, Burton JR. Surgical Guidelines for Perioperative Management of Older Adults: What Geriatricians Need to Know. J Am Geriatr Soc 2017; 65(6): 1339-1346
http://onlinelibrary.wiley.com/doi/10.1111/jgs.14877/full
Mohanty S, Rosenthal RA, Russell MM, et al. Optimal Perioperative Management Of The Geriatric Patient: Best Practices Guideline from ACS NSQIP®/American Geriatrics Society. ACS NSQIP®/American Geriatrics Society 2016
Berian JR, Rosenthal RA, Baker TL, et al. Hospital Standards to Promote Optimal Surgical Care of the Older Adult: A Report From the Coalition for Quality in Geriatric Surgery. Annals of Surgery 2018; 267(2): 280-290, February 2018
AORN (Association of periOperative Registered Nurses). AORN Position Statement on Care of the Older Adult in Perioperative Settings. AORN 2015
https://www.aorn.org/-/media/aorn/guidelines/position-statements/posstat-patients-older-adults.pdf
Print “Prepping the Geriatric Patient for Surgery”
April 17, 2018
More on Tests Pending at Discharge
The problem of significant abnormal test results “slipping through the cracks” is a serious cause for preventable adverse patient outcomes and a leading cause of malpractice settlements. A subset of this problem has to do with “tests pending at discharge”. This refers to tests that were performed during an inpatient hospitalization for which the formal interpretive report has not been completed before the patient is discharged from the hospital. We’ve discussed this in our Patient Safety Tips of the Week for March 1, 2011 “Tests Pending at Discharge” and August 21, 2012 “More on Missed Followup of Tests in Hospital” and the list of other columns below.
In our March 1, 2011 Patient Safety Tip of the Week “Tests Pending at Discharge” we discussed a systematic review on the safety implications of missed test results in hospitalized patients (Callen 2011). This is an issue we have harped upon in many previous columns and the findings in the new review are no less frightening. They found lack of followup on test results ranged from 20-60% for inpatients and 1-75% for emergency room patients. And the lack of followup had clinical implications since some of the results were considered critical or urgent or otherwise actionable.
A couple factors in recent decades have contributed to this problem. One is the pressure to shorten hospital lenghs of stay. The second has to do with the widespread adoption of hospitalist programs. Don’t get us wrong. We love hospitalists! But the nature of hospitalist scheduling often leads to reports being sent to a hospitalist who will not be at the hospital for a considerable period of time or even never again. In our March 9, 2010 Patient Safety Tip of the Week “Communication of Urgent or Unexpected Radiology Findings” we noted a study (Were et al 2009) which showed that only 16% of tests with results pending actually are documented in discharge summaries. They identified multiple changes in attendings as an issue and difficulty identifying the physician who will ultimately follow the patient after discharge. We also noted in our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks that studies have shown sending reports to two physicians, rather than increasing the likelihood someone will follow up, actually doubles the risk that no one will follow up (Singh 2009)!
Dalal and colleagues (Dalal 2018) at Brigham and Women’s Hospital (Partners HealthCare) recently reported results of a cluster-randomized controlled trial assessing the impact of automated notification of tests pending at discharge (TPAD’s) on documented follow-up in the EHR. (Note that we’ve described some of the design and implementation of such systems by Dalal and colleagues (Dalal 2011, Dalal 2012) in previous columns.)
Patients discharged from general medicine and cardiology services with at least one TPAD between June 2011 and May 2012 were assigned to intervention or usual care groups based upon the randomization status of their discharging attending and PCP. They adapted an established algorithm to identify actionable TPAD’s. All normal, near-normal, and benign results were excluded. 7.5% of all TPAD’s sampled were determined to be actionable and underwent subsequent chart review. Examples of actionable TPAD’s include malignant cells in pericardial fluid cytology, low vitamin D level, HIV genotype, positive urine culture, low protein C level, gastric biopsy positive for H. pylori, and positive hepatitis C antibody. Most commonly documented actions included establishing, changing, or confirming a diagnosis and communicating results with the patient.
Most TPAD’s were generated on patients discharged from general medicine services. The most frequent test type was chemistry/hematology. Most discharging attendings were male and had 5 years or less of experience. 66% of patients had non-network PCP’s. The proportion of actionable TPAD’s listed as pending in the discharge summary was 50.7% and 49.5% in the intervention and control groups, respectively.
The proportion of actionable TPAD’s with documented action was not statistically different for the intervention arm compared to usual care (60.7 vs. 56.3%). But almost all (97.4%) instances in the intervention arm who had action had evidence of documented action on the same day.
The proportion of actionable TPADs with documented action was significantly higher for pathology compared to other test types (77.2 vs. 48.5%). There was a non-significant trend towards increased proportion of actionable TPADs with documented action for patients discharged by hospitalists compared to non-hospitalists (62.3 vs. 54.4%). There was a significantly greater impact of the intervention on documented follow-up of actionable TPAD’s among patients with network PCPs (70 vs. 50%). There was no evidence of effect modification of the intervention by clinical service, provider type or experience, test type, or number of actionable TPAD’s per patient.
Even with the automated notification system there were still approximately 40 percent of patients who had no evidence of documented follow-up for actionable TPAD’s, including several patients with biopsy specimens that revealed malignancies.
The proportion of actionable TPAD’s lacking documented follow-up was 39.9% for acknowledgment, and 41.1% for action. Types of actionable TPADs without documented follow-up included abnormal vitamin levels (n = 25), pathology specimens (n = 15, including 6 malignancies); abnormal rheumatology titers (n = 9, including an extremely elevated anti-DS DNA titer); abnormal endocrine results (n = 8); abnormal viral tests (n = 8, including an elevated HCV viral load); positive microbiology cultures (4); and miscellaneous (32)
Notably their healthcare system also had separate notification systems running in parallel for pathology and radiology. The authors suspect that may account for the higher proportion of pathology follow up action documented and for the very low number of radiology TPAD’s identified (most significant radiology TPAD’s were identified prior to discharge).
Note that this study only included patients who were inpatients. It did not address the issue of patients seen in the ED and discharged before official reports of all tests were done. The ED is particularly vulnerable because the individual ED physician may not be returning to the hospital soon (or never in some circumstances). So the ED medical director or his/her designee must be assigned the task of going over the previous day’s tests to ensure no test results are “pending” and have not been acknowledged by the original ED physician. Similarly, particularly for radiology studies, each facility must have a system in place a system where the ED physician’s interpretation of an imaging study is reconciled with the official radiology report and any discrepancies get back to a party in position to take appropriate follow up action.
The other issue it does not address is the amended report. We discussed that in our Patient Safety Tips of the Week for October 2, 2012 “Test Results: Everyone’s Worst Nightmare” and March 12, 2013 “More on Communicating Test Results”. Each facility must have in place a system in which any report that is amended gets conveyed to a party responsible for the patient.
Although the study did not show significant improvement in the proportion of actionable TPAD’s with documented follow-up, they did observe significant improvement in time to documented follow-up favoring the intervention.
The study does demonstrate that the system designed at the Brigham resulted in significant improvement in documented follow-up for patients of network PCP’s and shortened the time to follow up action. One other positive aspect of the study is that Partners HealthCare clearly has a good algorithm for identification of potentially actionable TPAD’s (tests pending at discharge). In our Patient Safety Tip of the Week August 21, 2012 “More on Missed Followup of Tests in Hospital” we discussed some of the barriers to identifying all those pending test results and in being able to attribute responsibility for followup to the correct party.
Also, since the Brigham is a tertiary referral center and a very high percentage of inpatients were non-network patients (66% of their patients had non-network PCP’s), it might be anticipated that a system like theirs might be more effective in hospitals that have a higher proportion of in-network patients and PCP’s, such as community hospitals.
It's also encouraging that the systems for communicating significant results for radiology and pathology seem to be working well at the Brigham.
And it's encouraging that the percentage of discharge summaries identifying tests pending at discharge has improved since our original columns (the proportion of actionable TPAD’s listed as pending in the discharge summary was 50.7 and 49.5% in their intervention and control groups, respectively). But that’s still short of the 100% target we have.
But the Brigham study found that about 40% of actionable TPAD’s did not have follow-up documented in the EHR, including a few high-risk results such as malignancies. The study shows that we still have a big gap in “closing the loop” on test results when patients are discharged prior to official test result reports being available.
To address this gap, Dalal and team envision integration of newer digital health tools with the hospital's electronic health record that not only notifies discharging attending physicians and primary care physicians, but that empowers patients to make sure their test results are followed-up in a timely manner. They note that most major EHR vendors can extend existing functionality to externally notify clinicians of actionable TPAD’s via institutional email, secure messaging, or mobile app “push” notifications. They can also flag importance in subject headings or notification banners, facilitate knowledge transfer between key inpatient and ambulatory clinicians; and request acknowledgment electronically.
See also our other columns on communicating significant results:
References:
Callen J, Georgiou A, Li J, Westbrook JI. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf 2011; 20: 194-199 Published Online First: 7 February 2011
http://qualitysafety.bmj.com/content/20/2/194.full.pdf
Were MC, Li X, Kesterson J, et al. Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers. Journal of General Internal Medicine 2009; 24(9): 1002-1006
http://springerlink.com/content/57u6374273282457/?p=8d1facb4fd6c402a9b895f3a46a59022&pi=1
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586.
http://archinte.ama-assn.org/cgi/content/short/169/17/1578?home
Dalal AK, Schaffer A, Gershanik EF, et al. The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial, Journal of General Internal Medicine 2018; Published online 12 March 2018
https://link.springer.com/article/10.1007%2Fs11606-018-4393-y
Dalal AK, Schnipper JL, Poon EG, et al. Design and implementation of an automated email notification system for results of tests pending at discharge. J Am Med Inform Assoc 2012; 19(4): 523-528
http://jamia.bmj.com/content/19/4/523.abstract?sid=e567bfae-e816-4f48-8080-36ee4119062d
Dalal AK, Schnipper JL, Poon EG, et al. Design and implementation of an automated email notification system for results of tests pending at discharge. J Am Med Inform Assoc 2012; 19(4): 523-528
http://jamia.bmj.com/content/19/4/523.abstract?sid=e567bfae-e816-4f48-8080-36ee4119062d
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April 24, 2018
Review on Hourly Rounding
We’ve been big advocates of “hourly rounding”, also known as “purposeful rounding”, “intentional rounding”, and other names. Our July 26, 2011 Patient Safety Tip of the Week “Hourly Rounding” discussed how hourly rounding, when done well, not only improves patient satisfaction but also reduces nurse interruptions and may improve patient safety outcomes. Our September 2014 What's New in the Patient Safety World column “Update on Hourly Rounding” discussed some of the models and issues and barriers to implementation of hourly rounding programs.
Following a 2013 report on deficient patient care in one UK hospital, the UK mandated that all NHS hospitals implement intentional rounding. Now a recent systematic review paints a more pessimistic view of “intentional rounding” (Sims 2018). Sims and colleagues conclude that, despite widespread use of intentional rounding, their review highlights ambiguity surrounding its purpose and limited evidence of how it works in practice.
The researchers used a “realist synthesis” approach, a theory-driven approach to evaluating complex social interventions such as intentional rounding, using empirical evidence from the literature. A total of 44 papers met their inclusion criteria. Over half the studies were from the US.
They described a “typical” intentional rounding program as having the following characteristics:
During each round, the following standardized protocol is used by a nurse for each patient:
n An opening phrase is used by the nurse to introduce his or herself and to put the patient at ease.
n Scheduled tasks are then performed.
n A discussion of the four key elements of the round, often called the ‘4 P’s’:
n An assessment of the care environment, such as checking the temperature of the room or any fall hazards.
n Ending the interaction with a closing phrase such as “Is there anything else I can do for you before I go?”.
n The patient is informed of when the nurse will return.
n The nurse documents the round.
If patients are unable to respond during the round, the nurse may follow this process with family members.
A majority of the papers in the systematic review found:
n A reduction in call bell use by patients
n A reduction in falls
n A reduction in pressure ulcers
n A reduction in patient complaints
But studies failed to show an impact on readmissions or overall costs.
The authors identified eight proposed mechanisms or reasons for implementing intentional rounding:
(1) when implemented in a comprehensive and consistent way, intentional rounding improves healthcare quality and satisfaction, and reduces potential harms
(2) embedding intentional rounding into daily routine practice gives nurses ‘allocated time to care’
(3) documenting intentional rounding checks increases accountability and raises fundamental standards of care
(4) when workload and staffing levels permit, more frequent nurse–patient contact improves relationships and increases awareness of patient comfort and safety needs
(5) increasing time when nurses are in the direct vicinity of patients promotes vigilance, provides reassurance and reduces potential harms
(6) more frequent nurse–patient contact enables nurses to anticipate patient needs and take pre-emptive action
(7) intentional rounding documentation facilitates teamwork and communication
(8) intentional rounding empowers patients to ask for what they need to maintain their comfort and well being.
Regarding consistency and comprehensiveness of care, they did find evidence that intentional rounding prompted and guided the delivery of care, helping staff remember to conduct all aspects of care on every round. However, there was often a tendency to pay more attention to high risk/high need patients. Also, time limitations, low staffing levels and conflicting priorities made meeting this goal more difficult.
Evidence of providing more time to provide care was conflicting. The reduction in call bell use often did provide more time for care but staff attitudes varied considerably, with some staff feeling this was “nothing new”, that it increased their workload and actually took time away from care, and that documentation of rounding also took time away from care.
Regarding accountability (both personal and organizational) was perceived by some to underpin intentional rounding. But there was some concern that both personal accountability and organizational accountability focused more on staff compliance with documentation procedures rather than actual care rendered (i.e. “tick boxes” mentality).
With regard to nurse–patient communication, it was widely reported that intentional rounding increased the amount of time nurses spent in direct contact with patients/family members and thereby increased the frequency of their communications. But there was little evidence about the quality of the communication. In fact, some staff even felt that using predetermined intentional rounding scripts stripped nurse–patient communications of authenticity and routinised patient contact.
Regarding nurses’ anticipation and proactively addressing patient needs, staff often stated intentional rounding enabled them to be proactive rather than reactive (eg. responding to call bells) in anticipating patient needs and that this was associated with increased patient satisfaction and reassurance, decreased patient anxiety, a reduction in call bell usage, and an overall sense of calm on the ward and decreased staff workload. Moreover, intentional rounding was also reported to enable nurses to intervene earlier when a patient’s medical condition was deteriorating.
Interestingly they cited one study (Berg 2011) that changing position and getting in and out of bed were identified as activities that could be anticipated and addressed by intentional rounding but not pain management or toileting needs. That is of concern since one of our most consistent recommendations for prevention of falls is using hourly rounding to anticipate toileting needs.
They also found supportive evidence that intentional rounding has a positive impact on staff communication and teamwork, as well as empowering patients.
The authors identified a number of discrepancies between how intentional rounding is purported to work and how it operates in practice, as well as international differences in how the intervention has been implemented. They note that intentional rounding in the US has a more structured approach, compared to the UK where the approach is more flexible. They think the difference may be in the impetus for implementing intentional rounding. They note that in the US, intentional rounding programs are often marketed, whereas in the UK they responded to the mandate. The authors also note that poor understanding of how and why intentional rounding works as a major challenge to learning, replication and sustainability of the intervention.
The authors conclude that weak evidence did not give sufficient justification for the implementation of intentional rounding in the UK (though it reviewed international literature, the study was really focused on intentional rounding in the UK).
Probably the best contribution of this systematic review is the collection of an extensive bibliography. If you want to see the many underlying individual studies reviewed, there are links to most of them.
We’ve also previously voiced some of the concerns raised in this review and acknowledge that there is often a disparity between nursing leadership and frontline nurses regarding the practice. But we remain advocates of hourly rounding or intentional rounding programs. We hope you’ll go back to our July 26, 2011 Patient Safety Tip of the Week “Hourly Rounding” and our September 2014 What's New in the Patient Safety World column “Update on Hourly Rounding”. We feel that, especially in the US, well done hourly rounding not only improves patient satisfaction but also reduces nurse interruptions and improves patient safety outcomes (such as falls, pressure ulcers, and patient complaints). The latter column also discusses some of the models and issues and barriers to implementation of hourly rounding programs. In particular, hourly rounding models may include “reliable” rounders and “variable” rounders to deal with “predictable work” and “unpredictable work”.
You should also note that some of the functions that underlie the utility of hourly rounding programs might be carried out by specialized teams operating independently of the unit nursing staff. Such teams might address issues such as turning and repositioning patients, attending to toileting activities, feeding patients who need assistance feeding, and ambulating. We know of no formal studies that have looked at the relative cost effectiveness of using such teams compared to more traditional nurse hourly rounding programs.
References:
Sims S, Leamy M, Davies N, et al. Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why. BMJ Qual Saf 2018; Published Online First: 14 March 2018
http://qualitysafety.bmj.com/content/early/2018/03/14/bmjqs-2017-006757
Berg K, Sailors C, Reimer R, et al. Hourly rounding with a purpose. Iowa Nurse Reporter 2011; 24: 12-14
https://www.highbeam.com/doc/1G1-289217372.html
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May 1, 2018
Refrigerator Alarms
In our presentations on alarm safety we always point out that not all alarms are connected directly to patients. But other alarms may have a significant impact on patients and need to be incorporated into you alarm management program.
One example of such alarm that we usually raise is that which responds to the temperature in a refrigerator falling out of the desired range. That has been in the news lately because incidents at two separate fertility clinics involved loss of tissue when the temperatures in the refrigerating units rose above levels necessary to preserve the specimens. But you may have refrigerators that store blood products or tissue implants or vaccines that require specific temperature ranges for storage. You may also have temperature alarms that require a specific temperature range in your IT server farm.
On the same day in early March of this year, rare refrigerator malfunctions were experienced at two fertility clinics, one in Cleveland and one in San Francisco, potentially affecting thousands of patients' eggs and embryos (Nestel 2018). At the clinic in San Francisco a senior embryologist noticed, toward the end of the day while doing routine checks of the tanks, that the nitrogen level in one tank was very low. The tank with the depleted levels of liquid nitrogen was refilled. Another filled tank stored downstairs in the building replaced it and the tissue specimens were transferred. That facility brought in independent experts and are conducting a full investigation (Brookbank 2018) but details of that investigation are not known at this time.
The situation in Cleveland apparently was a little different. A letter of disclosure and apology sent to 950 patients potentially impacted by loss of eggs and embryos (Buduson 2018) said a remote alarm system on the storage tank containing the eggs and embryos, which was designed to alert an employee to temperature fluctuations, was turned off. It was unclear when the remote alarm was turned off, but an alert to an employee as the temperature inside the tank began to rise was not sent or received. It was unclear who turned off the alarm and how long the alarm had been turned off. The lab was not staffed on the night of the malfunction. There was also a history of malfunctions involving the storage tank. For weeks prior to the malfunction there apparently had been difficulty with what is called the “liquid nitrogen automatic fill” and the facility was working with the manufacturer to correct the problem.
While the Cleveland letter apparently discussed the role of human error, there obviously were also system problems and other factors that contributed to the unfortunate incident. Periods around maintenance of equipment are vulnerable times. We discussed this in our August 7, 2007 Patient Safety Tip of the Week “Role of Maintenance in Incidents”, in which we discussed the excellent work of James Reason and Alan Hobbs plus that of Don Norman. Also, in our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms” and several other columns on alarms, we noted instances where the oxygen blender alarms on ventilators had been disabled during maintenance and were not corrected prior to use in patients. When maintenance is done on any equipment we recommend to staff doing maintenance have a checklist they use to remind them of things they must do. And one of those items would be to restore any alarms they might have disabled during the maintenance.
There was also apparently a workaround being used in the Cleveland case. Liquid nitrogen was being added to the tank manually because they were having issues with the mechanism is that is supposed to automatically refill the liquid nitrogen to keep the specimens cold (Wamsley 2018). The liquid nitrogen was brought in a container from a nearby lab and poured into the tank. A letter sent to patients by the clinic said. "The liquid nitrogen levels in the tank were monitored and appeared to be appropriate on Friday and Saturday, but we now suspect that may not have been the case."
And we are not told of any potential design issues. For example, how do you know the alarm is powered and active? The smoke detector or carbon monoxide detector in your home has a button you press that indicates the alarm is functional. Is there a similar capability on these refrigerator alarms?
When dealing with valued resources, such as the specimens in a fertility clinic, redundancy and backup systems are a must. We don’t know details about their systems but, obviously, the technology is available to indicate an alarm malfunction or disconnection. We get a “your motion camera has been disconnected” message by email and text message every time our motion detection camera gets disconnected from our WiFi system. We would assume similar capabilities should exist to alert someone when a freezer alarm system has been disconnected (though, even then, you might anticipate an event that disables both your refrigerator alarm and your WiFi system).
In our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” we gave the following anecdote: You have an alarm that responds to the temperature in a refrigerator dropping below a set value to protect against loss of the medical products inside. You took great care to make sure the thermometer was not on the same electrical supply as the refrigerator. However, the battery on the thermometer had not been checked recently and had no charge when the refrigerator actually lost power. All the medical products in the refrigerator are lost.
And, of course, the other issue was that the event took place on a night when the lab was not staffed. Even when the alarm is working properly, you need to make sure your system of response is also working. We once did a root cause analysis (RCA) on an incident where the temperature in a refrigerator storing implants rose above the desired range. An alarm was triggered. Of course, these incidents never happen during the daytime when all sorts of staff are around to respond! They tend to happen at night or on weekends. The alarm went to the ER (that was one area staffed 24 x 7, so someone would be alerted), who then notified the nursing supervisor. The nursing supervisor attempted to contact the on-call biomedical engineer. That call went initially to someone who was not actually on-call. By the time the biomedical engineer actually on-call was reached, several hours had gone by and the tissue implants were no longer usable. Fortunately, no patient was harmed or inconvenienced by the episode, but the facility did incur some financial loss due to the loss of the implants.
There should be a checklist and set of instructions informing the person responding to the alarm what to do. Probably the best place to put this is right on the refrigerating unit. You don’t want to bury it in a thick policy manual where the respondent may not even find it in a timely fashion.
You also want to make sure that you have an appropriate “escalation” practice (i.e. who to call next if the first person called fails to respond in a timely fashion). While we have such escalation procedures in place for clinical staff, many facilities are less deliberate with regard to non-clinical staff escalation procedures.
Given the low statistical probability of such events occurring at two remote fertility clinics on the same day. we’d question whether this was truly coincidental or whether such systems could be vulnerable to hacking. We would assume the two facilities have communicated with each other about the coincidence and have assessed for potential hacking.
The Cleveland facility certainly did the right thing in being forthright and honest in letting affected patients know about the error(s) and expressing heartfelt apology. It also let them know that a proper investigation was being undertaken to address problems so a similar incident does not recur in the future. The hospital system says it is refunding storage fees to those patients who had stored eggs and embryos, as well as offering tailored emotional and medical support, including a free round of IVF for those who want it (Wamsley 2018). The hospital system isn't asking patients to sign a release in order to access the services. Our numerous columns on disclosure and apology (listed below) illustrate that, not only is disclosure and apology the right thing to do, it likely reduces legal costs in the long run as well. Similarly, the Cleveland facility response is in keeping with the trend to communication and resolution programs (columns also listed below).
Most healthcare incidents involve a single patient (aside from those misidentification incidents that involve pairs of patients). But sometimes incidents, like the ones above, impact multiple patients and the issues there become much more complex. We refer you to our June 16, 2009 Patient Safety Tip of the Week “Disclosing Errors That Affect Multiple Patients” for recommendations in such cases.
Lastly, the fertility clinic incidents led to a blog on responding to bad press (Laub 2018) that is worth your review. In the highlighted video Ron Harman King, of Vanguard Communications, offers the following four “commandments” when dealing with bad press:
Read that blog and watch the video. We agree with King’s sage advice. But there is, perhaps, one additional recommendation we’d make. Though we fully endorse the concept of “don’t run and hide”, we also caution organizations to avoid unnecessarily rekindling the bad press after it has disappeared from attention. We’ve seen too many organizations try to offer excuses, often lame ones, for bad incidents long after the media cycle had bypassed them, only to get the issues back on the front page.
We’ll bet your facility likely has some refrigerators or freezer units that store important blood or tissue specimens or vaccines. And we know your IT server farm relies on optimal temperature ranges. But how many of you have ever questioned what would happen if there was an alarm malfunction in one of these units? Have you done a FMEA (failure mode and effects analysis) of such alarm systems? Do you look at these alarms when you are doing Patient Safety Walk Rounds? Are the appropriate people alerted when these alarms are triggered? Do those people know how to respond when such alarms trigger? Is there a checklist that helps responders take all necessary steps when such an alarm triggers? Do you know how such alarms are powered and what the impact of a power failure or battery failure might be? Do you have backup systems in place?
And when you do your FMEA, don’t forget to ask if the necessity for storing things in the refrigerator was appropriate in the first place. In the example RCA we discussed above, there was actually little reason for storage of the implants. They could have just as easily been obtained on a just-in-time basis. They were just creating unused excess inventory.
So what should you be doing?
Lastly, we need to learn from other incidents and near misses. Several years prior to the incident discussed above where the implants were lost due to the freezer failure, there had been a similar episode in the blood bank and another one in the IT server farm. Some of the same system problems in those incidents were in play in the current incident. Yet those events had been dealt with strictly at the departmental level and lessons learned not shared with other departments. No lesson learned is so small that it shouldn’t be shared with others. A high performing health system has a culture of disseminating lessons learned no matter how “small” those lessons learned may seem. Moreover, knowing which types of action plans actually work is invaluable.
Despite our caution about rekindling the incident in the media, we would also hope that the lessons learned when each of these fertility organizations does their root cause analysis (RCA) would somehow be disseminated because virtually all other healthcare organizations may be vulnerable to similar incidents with the refrigerator or freezer systems they use for a variety of purposes.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “What’s Happening to “I’m Sorry”?”
October 2017 “More Support for Disclosure and Apology”
April 2018 “More Support for Communication and Resolution Programs”
Other very valuable resources on disclosure and apology:
References:
Nestel ML. Fertility clinic cryostorage fridge malfunction on same day as Cleveland hospital. ABC News (abc7.com) 2018; March 12, 2018
Brookbank M. Second fertility clinic suffers malfunction on same day as University Hospitals. News5cleveland.com 2018; Mar 11, 2018 Updated: Mar 12, 2018
Buduson S. Human error blamed for Ohio fertility center malfunction, says 4,000 eggs and embryos lost. TheIndyChannel 2018; Mar 27, 2018
Wamsley L. Ohio Fertility Clinic Says 4,000 Eggs And Embryos Destroyed When Freezer Failed. NPR Vermont Public Radio 2018; March 28, 2018
Laub G. The Four Commandments of Confronting Bad Press - Ron Harman King offers insights from the university of hard knocks. MedPage Today 2018; March 28, 2018
https://www.medpagetoday.com/blogs/wiredpractice/72036
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May 8, 2018
Heparin Overdose
It’s been 10 years since we had lots of headlines about deaths related to inadvertent overdosing with heparin. Most of the cases discussed back then pertained to accidental use of high-dose heparin “flushes” in children and infants (see the list of prior columns at the end of today’s column).
A recent report from the California Department of Public Health (CDPH 2018) brings the heparin issue back into the spotlight. A patient with chronic renal failure requiring dialysis was admitted with altered mental status, worsening renal failure, and a clotted A-V fistula. She was sent to the Interventional Radiology Department for a procedure to declot the A-V fistula. During the procedure she received 25,000 units of heparin diluted in a 250 milliliter bag of saline. She subsequently developed internal bleeding that led to her death.
The CDPH report notes that a physician asked for a heparin drip in a pressure bag. The nurse said she asked the physician “do you want 25,000 units in a 250 milliliter bag of saline?” and he responded “yes”. The nurse connected the IV tubing to the 250 milliliter bag of concentrated heparin and the physician manually controlled the rate of infusion with a roller clamp. No double checks were performed. The nurse later stated she did not think the physician intended to infuse the entire bag, otherwise she would never have “spiked” it (connected the IV tubing to the bag).
After the procedure a radiology technician showed the empty bag to a second nurse, who recognized that this was a much higher dose of heparin than usually used. Apparently, the normal dose for this procedure is 1,000 units of heparin in 500 milliliters of saline. That nurse informed the other nurses, the physician, and the radiology technician of the situation.
Upon return to the ICU the patient was noted to have bleeding from her arm and lab studies revealed a prolonged PTT and that her hemoglobin had dropped from 10 to 5.9. The patient subsequently died of hypovolemic shock.
In a subsequent interview with the CDPH, the physician recalled the nurse asking if he wanted a heparin drip but did not recall discussing the dosage. He recalled answering “yes, heparin in saline” and that his usual practice was to use 500 units of heparin per liter of saline for the drip.
The CDPH report and hospital response focus largely on the fact that no double check was performed before the heparin dose was administered. The hospital’s policy did call for a double check of IV heparin doses by two qualified health care professionals. A second RN was expected to validate and document the correct dosage. But in this case there was no double check by either another nurse or the physician.
The hospital’s plan of correction (POC) did focus on the issue of double checks, requiring that checks be done by two qualified health care professionals for all high-alert medications (of which heparin is one).
Double checks do have problems of their own (see our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”) but note that we still consider double checks to be an action of intermediate strength worth using in multiple situations, particularly for all high-alert medications. But they need to be truly “independent” double checks.
But there are several other factors that contributed to this adverse event. First, and foremost, this was a verbal order. Verbal orders are prone to error (see our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders”). Verbal orders should only be used in emergency circumstances or in circumstances where it is impractical for a physician to enter the order. When verbal orders are used, there must be “readback” where the nurse receiving the order specifically reads back all the information pertinent to dosing. That did not happen in this case. In fact, this was really a “reverse verbal order”! Though the physician had requested a heparin drip, it was really the nurse who initiated the specific order. Hence, the required “readback” would have fallen to the physician.
The fact that the whole process really took place verbally also bypassed several patient safety tools we use in medication safety. No order was placed in a CPOE system, which could have provided clinical decision support tools to ensure proper dosing. Also, the lack of input into an IT system precluded use of a barcoding system that also could have served as another line of defense against medication error.
Remember, this event took place in an interventional radiology suite. Not all hospitals have all their individual units connected to the hospital-wide electronic medical record and, hence, do not have integration with tools like barcoding and CPOE with clinical decision support. In some cases, it is truly a lack of IT integration, In others, it is a matter of culture.
In this hospital’s POC, they began using an upgrade of their EMR in the interventional radiology area and cath lab. This included a one-step medication order entry section and a section for documentation of administration. It requires entry of concentration for all high-alert medications. They note the physician can review all in one screen.
We’ve also pointed out in other columns the tendency to consider heparin not as a medication, particularly when heparin “flushes” are being used to keep IV lines open. Unfortunately, that cavalier attitude to heparin is all too widespread.
And then there is the question we always ask “why are formulations of such high-dose, concentrated heparin available on the unit in the first place?”. Does the interventional radiology unit do any procedures that would require such high-dose, concentrated formulations? If not, such formulations should be available only in the pharmacy, so that staff on the units cannot inadvertently administer overdoses. This is akin to the old problem of patients dying from injection of concentrated potassium chloride on patient care units. That problem was only solved when we removed vials of concentrated KCl from units other than the pharmacy. In this hospital’s POC their Pharmacy did an audit of medication cabinets in the Angio Lab and removed all 25,000 units/250 milliliter heparin bags. They also now have Pharmacy affix a high-alert double check sticker on all 25,000 units/250 milliliter heparin bags.
Removal of the high-dose formulations from “floor stock” is what we consider a strong intervention. It fits in the category of a constraint or forcing function, which are the strongest action steps (see our March 27, 2012 Patient Safety Tip of the Week “Action Plan Strength in RCA’s” and our slide show “Weak vs. Strong Responses to an RCA”).
Have you done an inventory to ensure you have no “floor stock” of high-dose heparin formulations? And are all your units, including your OR and radiology and procedural units, integrated with your EMR or at least have their own IT systems that utilize CPOE, clinical decision support, and barcoding?
Perhaps the biggest lesson from the California case is that facilities are still vulnerable to this sort of preventable error.
See some of our prior columns on inadvertent heparin overdoses:
December 2007 “1000-fold Heparin Overdoses Back in the News Again”
May 2008 “UK NPSA Alert on Heparin Flushes”
July 15, 2008 “Heparin Flushes.....Again!”
References:
CDPH (California Department of Public Health). 2018. Intake Number CA00512428. Accessed April 21, 2018
Print “Heparin Overdose”
May 15, 2018
Helping Inpatients Sleep
Sleep medications (hypnotics) have many potential adverse effects when given long-term. But they also have potential adverse effects even when used in the short-term. In hospitalized patients they increase the risk for falls and delirium. Therefore, we like to avoid them in hospitalized patients. But, at the same time, the hospital environment is not conducive to normal sleep-waking cycles.
Way back in 2009 we discussed a hospital’s attempt to improve patients’ sleep while reducing the use of sleep medications (see our August 2009 What's New in the Patient Safety World column “Bold Experiment: Hospitals Saying No to Sleep Meds”). But little has been published about subsequent hospital attempts to go hypnotic-free.
Our August 6, 2013 Patient Safety Tip of the Week “Let Me Sleep!” described a physician’s own account (Ubel 2013) of problems sleeping as a hospital inpatient and went on to discuss the numerous interventions we do that disturb a patient’s sleep (such as vital signs and blood draws). In that column we discussed the Hospital Elder Life Program (HELP) and the “Somerville Protocol” interventions to reduce interruptions to sleep and promote more normal circadian day-night cycles. We discuss these again below.
Now a new non-pharmacologic multidimensional program at an academic tertiary care hospital produced promising results (Herscher 2018). Components of the intervention were:
The 5-question Richards-Campbell Sleep Questionnaire survey was given to randomly chosen patients the following morning. As compared to 49 pre-interventions surveys, scores increased on four of the five questions in 56 post-intervention surveys. There was also a 15.3% increase in patients answering “always” to the HCAHPS question pertaining to quietness at night in the post-intervention period.
The authors consider the results preliminary and will be assessing for longer term sustainability. The abstract also did not report whether the intervention resulted in less use of sleep medications, though we presume it likely did.
In our “Let Me Sleep!” column we noted that the Hospital Elder Life Program (HELP) program (Inouye 2013) includes a systemic effort to improve sleep in hospitalized patients by noise reduction, a nonpharmacologic sleep protocol, and coordination of nighttime care. Inouye points out that besides vital sign monitoring and blood draws, patients’ sleep is often disrupted by medication administration, IV changes or IV alarms, intermittent pneumatic compression devices, breathing treatments, fingersticks for glucose monitoring, paging systems, room or hallway lights, conversations, cleaning and waxing floors at night, etc. Moreover, Inouye notes there is often a striking lack of coordination amongst staff that could minimize these disruptions. Simply having the phlebotomist tag team with the nurse or aide doing vital signs could avoid one disruption.
Another study (Bartick 2010) implemented the “Somerville Protocol” and documented a 38% reduction in patients noting sleep disruption due to hospital staff and a 49% reduction in patients receiving prn sedatives (actually a 62% reduction for patients aged 65 and older). The protocol consisted of 10 components:
A couple of those interventions merit further discussion. At many (perhaps most) hospitals, the incoming nursing staff gets vital signs when their shift starts. Hence, many patients get their vital signs checked between 11PM and midnight. Simply changing policy and procedure so that vital signs are checked by the outgoing staff at 10PM can help avoid one obvious potential sleep disruption. (Of course, you’d have to look for potential unintended consequences such as interfering with shift handoffs).
Getting physicians to understand that “three times daily” and “every 8 hours”, for example, are not the same takes some time and hard work. If I order a medication today at 10AM and enter it as “every 8 hours” my patient will be wakened at 2AM to get a dose. On the other hand, if the order is written for “three times daily” the hospital will have standard times that such are given to avoid that disruptive nighttime dose. (Note that you have to be very careful. Today’s CPOE systems often don’t make it clear when the first dose will be given. We have seen some systems where the first dose or even all the first day’s doses will not be given when the order is written this way.)
A noise monitoring device for the nursing station doesn’t need to be expensive. If a teacher can use a free or $0.99 decibel meter for his/her iPhone to alert him/her to classroom noise exceeding a specified level, we can certainly find a cheap solution to avoiding excessive noise at the nursing station or elsewhere. But even Bartick and colleagues note that reduction in noise and light probably did not significantly improve patients’ sleep. Rather reduction in the physical disruptions probably played the major role.
But promoting natural sleep is not simply a nocturnal event. What you do during the daytime is also important in promoting sleep. Regular exercise is an example of an important contributor to nocturnal sleep. Reducing ambient light at night is highly recommended. But what about light levels at other times? In our December 2013 What's New in the Patient Safety World column “Lighten Up Your Patient’s Day” we noted a study (Bernhofer 2013) that used light meters and wrist actigraphy to assess the sleep-waking patterns of hospital inpatients and correlated those parameters with patients’ pain levels and mood. Light exposure levels were low and sleep time was poor and fragmented. There was little sleep–wake synchronization with light. Fatigue and total mood disturbance scores were high and inversely associated with light. Pain levels were also high and positively associated with fatigue, but not directly with light exposure. Low light exposure significantly predicted fatigue and total mood disturbance. They concluded that inpatients were exposed to light levels insufficient for circadian entrainment. Nevertheless, higher light exposure was associated with less fatigue and lower total mood disturbance in participants with pain.
Though the study was small (40 total patients) this research demonstrates the need for further studies to see if altering light exposure for inpatients would be beneficial in affecting sleep–wake disturbances, mood and pain.
Lastly, don’t forget that we often have ourselves to blame. It is still common for physicians to leave orders for prn sleep meds in the admission orders, presumably so no phone call is needed at night requesting such. In our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” we stressed the importance of avoiding inclusion of “prn” sleep meds in standard order sets.
Avoiding sleep meds and using non-pharmacologic interventions to promote sleep is something every hospital should strive for. Some of the system changes mentioned in today’s column and our previous columns to avoid unnecessarily waking patients at night should also be an important component of your program.
Some of our previous columns on safety issues associated with sleep meds:
August 2009 “Bold Experiment: Hospitals Saying No to Sleep Meds”
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
May 2012 “Safety of Hypnotic Drugs”
November 2012 “More on Safety of Sleep Meds”
March 2013 “Sedative/Hypnotics and Falls”
June 2013 “Zolpidem and Emergency Room Visits”
August 6, 2013 “Let Me Sleep!”
June 3, 2014 “More on the Risk of Sedative/Hypnotics”
References:
Ubel P. Sleep Deprivation in Hospitals Is a Real Problem. Simple changes can make recovery more restful, and better overall. The Atlantic 2013; June 19, 2013
Herscher M, Mikhaylov D, Turakhia P, et al. The Sleep Hygeine In The Hospital Project: Shh! Society of Hospital Medicine (HM) 2018 Annual Meeting: Abstract 413905. Presented April 9, 2018
https://www.shmabstracts.com/abstract/the-sleep-hygeine-in-the-hospital-project-shh/
Inouye SK. No Rest for the Weary…or the Sick: Comment on “A Prospective Study of Nitghtime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration”. JAMA Intern Med. 2013; (): doi:10.1001/jamainternmed.2013.7809 Published online July 1, 2013
http://archinte.jamanetwork.com/article.aspx?articleid=1705720
Bartick MC, Thai X, Schmidt T, et al. Decrease in As-needed Sedative Use by Limiting Nighttime Sleep Disruptions from Hospital Staff. Journal of Hospital Medicine 2010; 5: E20–E24
Bernhofer EI, Higgins PA, Daly BJ, et al. Hospital lighting and its association with sleep, mood and pain in medical inpatients. Journal of Advanced Nursing 2013; Article first published online : 27 OCT 2013, DOI: 10.1111/jan.12282
http://onlinelibrary.wiley.com/doi/10.1111/jan.12282/abstract
ISMP (Institute for Safe Medication Practices). ISMP’s Guidelines for Standard Order Sets. 2010
https://www.ismp.org/guidelines/standard-order-sets
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May 22, 2018
Hazardous Intrahospital Transport
We’ve identified the radiology suite as a high-risk area for untoward incidents in many of our columns, noting that most such incidents have little to do with the radiologic procedure being done. It simply reflects that many vulnerable patients with complex medical problems need to go to radiology, where many of the safety features we use elsewhere may slip through the cracks.
A recent report from the California Department of Public Health (CDPH 2018) illustrates the problem. A patient had been admitted after being found on the floor and noted to be in atrial fibrillation. He was placed on telemetry and had orders for serial EKG’s and cardiac enzymes. It is not clear from the report whether the atrial fibrillation was persistent but subsequent EKG’s apparently showed PVC’s with trigeminy. A nurse notified his physician about the trigeminy and he was begun on oxygen 2 L/min.
He was scheduled for an MRI scan of the head (reason not provided in report). The nurse apparently contacted the physician, who ok’d sending the patient for the MRI, though it did not appear the physician realized the patient would be transported without telemetry monitoring.
No RN accompanied the patient to the MRI suite and he was not monitored in transit nor connected to telemetry on arrival at the MRI suite. The MRI technician did call the telemetry unit and asked a nurse whether the patient needed monitoring and the answer was “no”.
The patient was initially advanced into the MRI machine but was pulled out when he complained of shortness of breath. He sat up and was placed on high flow oxygen again but agreed to attempt the MRI again. He then asked to be pulled from the MRI again. As the MRI tech moved the patient back to the hallway and assisted him getting back in bed, the patient had a cardiac arrest. A code was called but attempts at resuscitation were unsuccessful.
The hospital’s policy on intrahospital transports had been revised about two years earlier to enable registered nurses to utilize clinical criteria to discontinue telemetry for select patients for transport to and during a test.
The hospital, in its POC (plan of correction), again revised its policy and protocol for transport of monitored patients. It would require a physician’s order stating that the patient could be transported without monitoring. If telemetry or other form of monitoring is to be continued, an RN must accompany the patient to the receiving area. The POC also included appropriate dissemination of the revised policy, inservice training, and an audit of subsequent transports of telemetry patients.
Though the hospital POC mentions the hospital uses patient safety tools like the Lean Daily Management Huddle on each nursing unit and multidisciplinary hospital Safety Huddles, there is no mention whether the hospital utilizes checklists like the “Ticket to Ride”. We have highlighted “Ticket to Ride” in multiple columns (see list below). It was originally started to ensure that patients being transported had adequate oxygen supplies, since some studies showed that over half of patients transported to sites like the radiology suite ran out of oxygen.
It’s worth reiterating many of the points in our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport”. Most of the literature on the risks associated with intrahospital transport have dealt with critically-ill patients. While incidents do occur during intrahospital transport of non-ICU patients, those from ICU’s are the most vulnerable. The percentage of ICU patients needing such intrahospital transfer probably depends on a host of factors, such as nature of the patient population, imaging capabilities, etc. One study ((Van Velsen 2011) noted that about a third of ICU patients required intrahospital transports. The literature also suggests that the risk of incidents and adverse events during transports is also related to the time duration of the transport. Hence, events such as CT scanning tend to be associated with more incidents because they require more time (PPSA 2005). We’ll also bet that the percentage of incidents related to transports to the MRI suite has been increasing as MRI scanning has superseded CT scanning for so many conditions.
The overall rate of incidents during intrahospital transports is difficult to glean from the literature. In our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” we noted studies from the 1980’s and 1990’s that showed rates of transport incidents as high as 70%. A paper by Smith et al (Smith 1990) noted adverse events during 34% of all ICU transports but transport of ICU patients to the CT suite was associated with a 71% incidence of adverse events. Those high rates of transport incidents have probably diminished somewhat. Some authors had previously noted an incidence of 3.7% (Van Velsen 2011) but when they prospectively monitored transports (Brunsveld-Reinders 2015) they found that in 26% of 503 transports to Radiology one or more incidents occurred.
Probably the most comprehensive review of incidents related to intrahospital transport came from the Australian Incident Monitoring Study in Critical Care, reported by researchers from Australia and Johns Hopkins (Beckmann 2004). They found 191 incidents related to intrahospital transport from 37 Australian ICU’s between 1993 and 1999. Roughly a third (31%) of the incidents had serious adverse outcomes, with major physiological derangement in 15%, physical/psychological injury in 4%, death in 2%, and prolonged hospital stay in 4%. In addition, patient/family dissatisfaction occurred in 7%. The site to which the transport occurred was evenly split between the Radiology suite and the OR, with some transports to the ward, ER, or other sites. And, of course, we refer you back to our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?” for a comprehensive discussion of all the things that can go wrong when a patient is sent to the radiology suite.
We also refer you back to our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” for discussion about the many factors contributing to incidents related to intrahospital transports. These include equipment failures, oxygenation issues, battery/power issues, and things like attention to patient hydration. And don’t forget the problems that arise when sending diabetic patients off for substantial periods of time (what to do with their insulin, planning for meals, etc.). We refer you to the Netherlands study itself (Brunsveld-Reinders 2015) to actually see the checklist they created for intrahospital transports. The article also addresses transport team composition (which may vary depending upon whether the patient is ventilated or on pressors or inotropes) and education/training needs for members of the transport team.
A good “Ticket to Ride” type checklist for intrahospital transport should cover all three phases of transport: pre-transport, during-transport, and post-transport (Jarden 2010, Brunsveld-Reinders 2015)
Of course, when doing an RCA (root cause analysis) of such cases, there are always two other questions you should ask:
Though we cannot answer these two questions based on the limited amount of information in the CDPH report, the questions are still important. The first question is important since one key component of most hospital alarm management programs now is reducing the use of unnecessary telemetry (see our Patient Safety Tips of the Week for October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”, August 16, 2016 “How Is Your Alarm Management Initiative Going?”, and October 17, 2017 “Progress on Alarm Management”).
The second question is important because we often see transports from ICU’s for imaging or other testing that are really of marginal value in patient management. In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we noted a commentary by Shirley and Bion (Shirley 2004) which noted the importance of making the decision about whether to transport a patient. They note that such decision “should be made by a senior, experienced and appropriately skilled clinician who remains responsible for the conduct of the transfer”. The potential benefits of a transport must be critically weighed against the potential risks. Beckmann et al. (Beckmann 2004) cite studies suggesting that care plans were changed for patients after such transports in only 24-39% of cases. So one really needs to consider how likely the imaging study (or other procedure the patient may be going for) is really going to change patient management.
In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we discussed “the 5 W’s” of intrahospital transport (Day 2010). The first “W” is “Why” or “Why does the patient need to leave the ICU for the procedure?”. Important questions to ask here are “Are there bedside alternatives for the procedure? And “Is the patient’s condition stable?”. If the patient is considered unstable, the next questions are “Is the transport for a lifesaving intervention?” and “Is the transport to a diagnostic test pivotal to decision for emergent plan?”. Day’s second “W” is “Who”. This included both who is the patient and who will be caring for the patient and, importantly, will a handoff be required? The third “W” is “What” and refers to equipment, airway, ventilator support, circulatory support, and special considerations (eg. spine stability, intracranial pressure monitors, etc.). Under the fourth “W” for “When” Day discusses considerations about coordinating with the timing of the test or procedure (eg. fasting or withholding anticoagulants for procedures), renal protective protocols for contrast-using procedures, and collaborating with other healthcare providers. The last “W” is for “Where” which includes details about the route to be taken, issues regarding MRI safety if going for MRI, etc.
Intrahospital transports, whether involving critical care patients or others, need to be undertaken with considerable planning. You need to ensure that you have systems in place to ensure the safety of the patients and tools like the “Ticket to Ride” checklists may facilitate safe transports.
Some of our prior columns on the “Ticket to Ride” concept:
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on patient safety issues related to MRI:
References:
CDPH (California Department of Public Health). 2018. Intake Number CA00462998. Accessed April 21, 2018
Van Velzen C, Brunsveld-Reinders AH, Arbous MS. Incidents related to intrahospital transport of patients in the ICU. Critical Care 2011; 15(Suppl 1): P535
http://www.ccforum.com/content/15/S1/P535
Pennsylvania Patient Safety Authority. Patient Safety Advisory. Is CT a High-Risk Area for Patient Transport? PA PSRS Patient Saf Advis 2005; 2(3): 11-12
http://patientsafety.pa.gov/ADVISORIES/Pages/200509_11.aspx
Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3):278-281
Brunsveld-Reinders AH, Arbous M, Kuiper SG, de Jonge E. A comprehensive method to develop a checklist to increase safety of intra-hospital transport of critically ill patients. Critical Care 2015; 19: 214 (7 May 2015)
http://www.ccforum.com/content/19/1/214
Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents relating to the intra-hospital transfer of critically ill patients: An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Medicine 2004; 30(8): 1579-1585
http://icmjournal.esicm.org/journals/abstract.html?v=30&j=134&i=8&a=2177_10.1007_s00134-004-2177-9&doi=
Jarden RJ, Quirke S. Improving safety and documentation in intrahospital transport: development of an intrahospital transport tool for critically ill patients. Intensive Crit Care Nurs 2010; 26: 101-107
Shirley PJ, Bion JF. Intra-hospital transport of critically ill patients: minimising risk. Intensive Care Medicine 2004; 30(8): 1508-1510
http://icmjournal.esicm.org/journals/abstract.html?v=30&j=134&i=8&a=2293_10.1007_s00134-004-2293-6&doi=
Day D. Keeping Patients Safe During Intrahospital Transport. Crit Care Nurse 2010; 30: 18-32
http://ccn.aacnjournals.org/content/30/4/18.full
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May 29, 2018
More on Nursing Workload and Patient Safety
There have been numerous studies linking poor nurse:patient ratios with adverse patient outcomes. But in our March 6, 2018 Patient Safety Tip of the Week “Nurse Workload and Mortality” we emphasized that simple nurse:patient ratios may not accurately reflect nursing workload and that it is likely workload that has a closer relationship with patient outcomes.
A recent study from Finland measured nursing workload by the RAFAELA system and compared workload to patient safety incidents and patient mortality (Fagerström 2018). The RAFAELA system uses daily data on patients’ care needs and the workload per nurse. It was developed in Finland in the 1990’s to help plan for better nursing staffing allocation than a simple nurse:patient ratio.
They found that when workload/nurse was above the assumed optimal level, the adjusted odds for a patient safety incident were 1.24 times that of the assumed optimal level. But when it was below the assumed optimal level the adjusted odds were 0.79. Similarly, when workload/nurse was above the assumed optimal level, the adjusted odds for patient mortality were 1.43 and when it was below the assumed optimal level the adjusted odds were 0.78.
Essentially, that meant that the odds for a patient safety incident were 10% to 30% higher, and for patient mortality about 40% higher, if the nurse workload as measured by the RAFAELA system was above the assumed optimal level. If OPC/nurse was below the level, the odds for a patient safety incident and for mortality were approximately 25% lower.
The authors conclude that in the latter situation nurses have more time for caring and observing each patient, resulting in reduction of the risk for adverse events and preventing the patient’s health condition from deteriorating.
The findings were statistically robust and clearly demonstrate the importance of nurse workload, rather than simple nurse:patient staffing levels, in relation to adverse patient events and mortality.
Many state legislatures have or are planning to mandate minimum nurse staffing levels based on number of patients per nurse. Massachusetts is one such state considering this mandate. In support of this mandate, the Massachusetts Nurses Association released results of a survey of a random selection from a complete file of the 100,000 nurses registered with the Massachusetts Board of Registration in Nursing. 90 percent of nurses responding admitted they lack adequate time to properly comfort and assist patients. An overwhelming majority of respondents felt that having to care for too many patients at one time was their most significant challenge in delivering high-quality care and that unsafe patient assignments were a problem. They linked such circumstances to medication errors, patient readmissions, and other patient injury or harm. Most also said hospital management does not typically adjust patient assignments to meet patients' needs.
The US is not the only country where such concerns have been voiced. In the UK, 55% of 30,000+ nursing staff responding to a 2017 survey reporting a staffing shortfall on the last shift they worked (Royal College of Nursing 2018). The Royal College of Nursing analyzed of nearly 18,000 nurses’ responses and identified 6 key themes from responses:
36% of nurses said they had to leave necessary patient care undone due to lack of time. This resulted in patients having to wait for treatment and care, including having access to toilet and washing, pain relief, and care such as action to prevent bed sores, ulcers and infections. Care left undone correlates with patient mortality. In our July 11, 2017 Patient Safety Tip of the Week “The 12-Hour Shift Takes More Hits” we discussed a study by Ball and colleagues (Ball 2017a), using survey data from the RN4CAST study to correlate measures of nurse-reported quality with shift duration. They found the rate of “care left undone” was 1.13 times higher for nurses working ≥12 hours. A previous study by Ball (Ball 2017b) showed that a 10% increase in the amount of care left undone by nurses was associated with a 16% increase in mortality.
In the UK survey, 41% of all shifts reported being short of one or more health care support workers. And 55% reported they spent too much time on non-nursing activities. This was especially noted when nursing skill mix was suboptimal and when staffing had to be supplemented by agency nurses, who were not familiar either with the patients or the intricacies of the IT systems. In our numerous columns on the “weekend effect” we’ve pointed out how non-nursing activities (due to lack of non-nursing ancillary personnel and lesser experienced nursing personnel) keep nurses from important patient care activities.
And, of course, it is difficult to divorce the nursing workload issue from the fatigue issue. Given the shortage of nurses in most locations, more and more nurses are working long shifts, whether voluntary 12-hour shifts or overtime. We’ve done many columns on the (mostly but not always negative) aspects of the 12-hour shift (see full list of columns below). One of the factors contributing to patient safety is collaboration (nurse-nurse and nurse-physician collaboration). A recent study (Ma 2018) found that overtime (more nurses working overtime or longer overtime hours) was associated with lower collaboration at the unit level. On the other hand, shift length was not. We might anticipate that one unintended consequence of mandated nurse staffing levels may be to increase the amount of overtime worked, perhaps subtracting somewhat from the benefit we expect to see from better nurse:patient ratios. In an ideal world we’d have an adequate supply of nurses so that we could optimize nursing workload without resorting to overtime.
Speaking of the 12-hour nursing shift, a new AHRQ-funded study will attempt to answer some of the lingering questions about the impact of such shifts on both patient safety and nurse health and well-being (Hatch 2018). The Washington State University study will involve 50 nurses working day shift and 50 nurses working night shift. Participants will report to the WSU Health Sciences campus for testing immediately following three consecutive, 12-hour day or night shifts. They’ll also be tested following three consecutive days off. Various methods will be used to test reaction times and cognitive capacity of the nurses. Nurses will also wear wrist-worn sensors to monitor sleep cycles. They’ll be tested in the College of Nursing’s Simulation Laboratory to see how well they perform a range of nursing skills like inserting an IV or monitoring vital signs. They’ll be asked to mentally calculate medication dosages. And finally, they’ll use simulators in the WSU Sleep and Performance Research Center to test their driving skills. The study will last 3 years but, hopefully, may answer some of our most serious concerns about the impact of 12-hour nursing shifts on patient care.
Efforts, for example by state legislatures, to mandate minimum nurse staffing levels based on number of patients per nurse are appropriate but may not go far enough. We need to refine measures of nurse workload and use such measures to allocate nursing resources more optimally. Even adjustments for patient acuity are not enough. The RAFAELA classification system seems to be a better measure of nurse workload. Given its success in Scandinavian countries, we need to look at adopting and refining it or similar measurement systems in other countries. We hope that hospitals and legislative or regulatory bodies will begin to look closer at measuring nursing workload via RAFAELA or the other measurement systems discussed in our March 6, 2018 Patient Safety Tip of the Week “Nurse Workload and Mortality”.
Some of our other columns on missed nursing care/care left undone:
November 26, 2013 “Missed Care: New Opportunities?”
May 9, 2017 “Missed Nursing Care and Mortality Risk”
March 6, 2018 “Nurse Workload and Mortality”
Our previous columns on the 12-hour nursing shift:
November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”
February 2011 “Update on 12-hour Nursing Shifts”
November 13, 2012 “The 12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The 12-Hour Nursing Shift: Debate Continues”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
September 29, 2015 “More on the 12-Hour Nursing Shift”
July 11, 2017 “The 12-Hour Shift Takes More Hits”
References:
Fagerström L, Kinnunen M, Saarela J. Nursing workload, patient safety incidents and mortality: an observational study from Finland. BMJ Open 2018; 8: e016367
http://bmjopen.bmj.com/content/8/4/e016367
MNA (Massachusetts Nurses Association). MNA: 'State of Patient Care in Massachusetts' Survey Released for National Nurses Week Finds Nurses Sounding the Alarm Over Deteriorating Conditions for Hospitalized Patients and Need for Safe Patient Limits. (Press Release). PR Newswire 2018; May 8, 2018
Royal College of Nursing (UK). Staffing for Safe and Effective Care: Nursing on the Brink. 13 May 2018
Ball J, Day T, Murrells T, et al. Cross-sectional examination of the association between shift length and hospital nurses job satisfaction and nurse reported quality measures. BMC Nursing 2017; 16: 26
https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-017-0221-7#CR25
Ball JE. Nurse Staffing Levels, Care Left Undone, & Patient Mortality in Acute Hospitals. Karolinska Institutet; Stockholm 2017
Ma C, Stimpfel AW. The Association Between Nurse Shift Patterns and Nurse-Nurse and Nurse-Physician Collaboration in Acute Care Hospital Units. Journal of Nursing Administration 2018; Published Ahead of Print Post Author Corrections: May 04, 2018
Hatch A. Study focuses on impacts of 12-hour shifts on nurses. WSU Insider 2018; May 1, 2018
https://news.wsu.edu/2018/05/01/study-focuses-impacts-12-hour-shifts-nurses/
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June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
Our past columns on iatrogenic burns have had a heavy focus on surgery-related things like burns related to instruments that had been flash sterilized and inadequately cooled prior to use or related to use of electrocautery devices.
But the Pennsylvania Patient Safety Authority recently published an excellent advisory focusing on iatrogenic burns unrelated to surgery (Field 2018). Cynthia Field analyzed burn events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in 2016 and found that over 60% occurred in non-surgical settings.
To our surprise, the most frequent thermal burns involved dietary spills of heated drinks or food (53 of their 107 non-surgical iatrogenic burns or 49.5%). Examples included spilled hot soup, coffee, and tea but microwaved foods were also mentioned.
Heating devices were the second most frequent culprits (30.8%). These included warm compresses and hot packs and powered devices such as circulating water or air blankets.
The third most frequent items associated with non-surgical iatrogenic burns related to MRI imaging. The report did not break down the nature of burns associated with MRI but we’ve discussed these before. Any ferromagnetic device can overheat when exposed to the magnetic forces of the MRI unit. That is why patients are questioned and examined for presence of such devices. Probably the most overlooked ones are transdermal drug patches that contain metal (see our March 2009 What's New in the Patient Safety World column “Risk of Burns during MRI Scans from Transdermal Drug Patches”). Others have involved wires on monitoring devices, particularly when coiled or looped.
And burns were also seen from defibrillator paddles, chemicals (irritant or caustic substances), and various electrodes or monitoring devices. There were also 6 cases related to ultraviolet light therapy and a smattering of other causes.
Field highlights our frequent point that burns are a function of not only temperature but also duration of exposure. The classic example is the flash sterilized tool that is warm to the touch, but when placed on the drapes over a patient’s abdomen in the OR, leads to a dermal burn. And she also notes our warnings that patients with impaired sensation are especially vulnerable to iatrogenic burns and those with impaired ability to communicate (eg. aphasia, dementia, etc.) may not be able to convey when they are in pain from an impending burn.
So we’ll add some of Field’s recommendations to the list from our September 5, 2017 Patient Safety Tip of the Week “Another Iatrogenic Burn” of things your organization should you do to minimize the risks of iatrogenic burns:
And Field’s recommendations:
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:
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
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June 12, 2018
Adverse Events in Cancer Patients
Adverse events are common in patients with cancer. Sometimes these are events potentially anticipated as a result of their treatment. But many adverse events in cancer patients are also potentially preventable.
Researchers at Memorial Sloan Kettering Cancer Center recently looked at a sample of cancer patients to see how often they suffered adverse events and how often such were preventable (Lipitz-Snyderman 2017). The sample included 400 randomly selected patients from a population of patients with lung, colorectal or breast cancer. Overall, they found 304 adverse events (AE’s), for an overall rate of 2.3 events per 1000 patient days (91.2 per 1000 inpatient days and 0.9 per 1000 outpatient days). Thirty-four percent of the patients had 1 or more AE’s and 16% of the patients had 1 or more preventable or mitigable AE’s. The AE rate for patients with breast cancer was lower than the rate for patients with colorectal or lung cancer. Sixty-three percent of AE’s occurred in the inpatient setting, for a rate of 79.0 AE’s per 100 hospital admissions.
Nearly a third of all AE’s (32%) were deemed definitely or probably preventable. The rate of preventable or mitigable AE’s for inpatients was 29.9 AE’s per 100 hospital admissions. For preventable AE’s, the rates were 31.52 per 1000 inpatient days and 0.24 per 1000 outpatient days. For mitigable AE’s, the rates were 3.82 and 0.08, respectively. The overall rate of preventable AE’s was 0.73 per 1000 patient days, and the rate of mitigable AE’s was 0.13 per 1000 patient days.
The AE and preventable or mitigable AE rates by setting differed by cancer type. The largest proportion of preventable or mitigable AE’s of the total AE’s belonged to lung cancer (47%), followed by colorectal cancer (36%) and breast cancer (20%). Regarding stage of disease, overall AE’s and preventable/mitigable AE’s occurred more frequently in patients with advanced disease for colorectal cancer, but not for lung or breast cancer.
The study does not go into great detail about the actual adverse events but does provide general categories for them. Infectious events (such as C. diff infection) were the most common AE’s. Other frequent types included things like mucositis, hematologic events like thrombocytopenia, and metabolic events like hypokalemia or hypomagnesemia.
Approximately half of all AE’s occurred within 3 months of the first treatment.
Regarding harm, 6% of overall AE’s and 4% of preventable AE’s were deemed to have resulted in permanent harm, to have required life-sustaining intervention, or to have resulted in death.
One of the types of adverse event that cancer patients are particularly vulnerable to is medication error. Complex regimens and multiple venues where they receive medications may be contributing factors. In our May 5, 2015 Patient Safety Tip of the Week “Errors with Oral Oncology Drugs” we described many of the other factors involved in such errors. In addition, chemotherapy agents are high-alert medications, meaning that errors related to these drugs have a high potential for causing patient harm.
The Pennsylvania Patient Safety Authority (PPSA) recently reported on over 1000 medication errors from outpatient hematology and oncology clinics reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) over a two year period (Banasser 2017). High-alert medications were reported in 55.5% of the events, with antineoplastic agents making up 94.3% of those medication errors reported with high-alert medications. (Other high-alert medications in this patient population included opioids and anticoagulants). But chemotherapy pre-medications, colony-stimulating agents, and corticosteroids were other agents involved in reports.
Though errors most frequently involved the prescribing node followed by the administering mode, errors occurred in every step of the medication use process (i.e., prescribing, transcribing, dispensing, administering, and monitoring).
Dose omissions (15.3%) and wrong dose/over dosage (13.1%) were among the most common errors encountered. The medication classes most frequently associated with dose omissions were antineoplastic agents, colony stimulating factors, and systemic corticosteroids.
Drugs involved most often in wrong dose/overdose events were antineoplastic agents and corticosteroids. Fortunately, two-thirds of these events were intercepted before reaching the patient and none resulted in patient harm. But the one-third that did reach the patient required monitoring or interventions to prevent harm.
Because so many of these drugs have dosages calculated based upon variables such as incorrect patient weight, height, body surface area (BSA), or serum creatinine level, it is not surprising that incorrect information about those factors contributed to some of the wrong dose errors. The authors point out that one patient safety intervention designed to prevent errors, i.e. having CPOE systems calculate dosages based upon such variables, will result in error if the underlying patient information is incorrect. We’ve done several columns on the importance of accurate and up-to-date weights (see list of columns below). Particularly in a cancer patient population, where weight loss may be frequent, it is important to have an up-to-date weight to use in dosage calculations. Some of the errors might also result from not having the most up-to-date laboratory information when dosage calculations or decisions about whether to proceed with a medication are made.
7.8% of errors were “wrong time” events. These were most often due to schedule errors or to delays in treatment.
Wrong drug errors also accounted for 7.8% of the errors. Name confusion was a common theme (for example, confusing PACLitaxel and DOCEtaxel or CARBOplatin and CISplatin). And our old favorite of confusion between morphine and HYDROmorphone was also reported.
Infusion-rate errors, omission of drugs or hydration, and improper preparation of drugs were also reported, albeit less frequently.
The PPSA paper has numerous recommendations to help avoid medication errors in this patient population and setting:
One very interesting study was reported at the recent Congress of the Oncology Nursing Society (Sato-DiLorenzo 2018). Laboratory values are typically checked prior to administration of chemotherapy to ensure the chemotherapy can be safely given. The researchers identified many near-misses related to this process and identified contributing causes, including lack of clear treatment criteria, a delay in lab processing, and patients expressing distress due to long wait times. They then developed two interventions to help prevent near-misses or actual adverse events:
Prior to the intervention there were 4-11 near-misses/week. In the 3 months after the intervention there was only a single near-miss. However, continued surveillance for the next 7 months found 0-3 near-misses/week. They identified barriers to full success, such as returning to past habits and the primary nurse simply telling the second verifying nurse that pre-treatment labs have been verified. They suggest there may be a limit to how human actions alone can produce sustainable changes.
We’ve done multiple columns on the limitations of double checks (see, for example, our Patient Safety Tips of the Week for October 16, 2012 “What is the Evidence on Double Checks?” and April 19, 2016 “Independent Double Checks and Oral Chemotherapy”). Nevertheless, double checks do have an important role when dealing with high-alert medications, like chemotherapy agents. But those must be truly “independent” double checks. That means the second healthcare worker needs to independently verify a dose calculation or lab data prior to discussing results with the other healthcare worker.
Our April 19, 2016 Patient Safety Tip of the Week “Independent Double Checks and Oral Chemotherapy” noted that the number opportunities for double checking is typically far less for oral chemotherapy compared to intravenous chemotherapy. Also, with oral chemotherapy in some settings you may be dealing with community pharmacists who are less experienced (compared with cancer center pharmacists) with the many complexities of chemotherapy regimens.
Two other issues relate to route of administration. We’ve done several columns on vincristine administered intrathecally rather than intravenously:
The Just Bag It! campaign calls for health care professionals to always dilute vincristine in a 50ml mini-IV drip bag and never in a syringe to minimize the risk of such incidents.
The other has to do with both the route and method of administration. The complex nature of some chemotherapy, involving multiple drugs and cycles, also contributes to medication errors in cancer patients. One type of chemotherapy adverse event we have been particularly concerned with is that in which a chemotherapy drug intended to be infused over several days gets infused much more rapidly (see our Patient Safety Tips of the Week for September 11, 2007 “Root Cause Analysis of Chemotherapy Overdose”, April 6, 2010 “Cancer Chemotherapy Accidents” and September 15, 2015 “Another Possible Good Use of a Checklist”). In those columns on home infusion chemotherapy we noted no one seemed to be asking “what is the highest dose that a patient could tolerate in one day (or less) if there was inadvertent administration of the infusion?”. A safety culture would design the protocol with sublethal dosages that would protect the patient in the event of “what can go wrong will go wrong”. It also would not put the healthcare workers at the “sharp end” in a situation none of us would want to be in. The same question should apply to oral chemotherapy regimens and be “What would be the highest aggregate dose a patient could tolerate over a specified period?” and avoid prescribing more than that inadvertently. Yes, the patient might be inconvenienced by having to do another physician or clinic visit to get a prescription for the next cycle or the second part of a complex regimen. But isn’t that preferable to receiving a chemotherapy overdose due to an avoidable error?
Then, there is also the issue of different doses of drugs depending upon the indication for the drug. There are some drugs, such as methotrexate, that are used for treating both cancer and other conditions. However, the dose and dosing frequency regimens are usually quite different when used for these conditions. We’ve frequently discussed the problem where methotrexate intended to be given on a twice weekly bases for an autoimmune disease erroneously gets given daily, resulting in toxicity for the patient. The opposite can also occur, where methotrexate is given only twice weekly for a cancer that merits daily administration.
And there is always yet the problem of patient misidentification. A recent report identified several factors that contributed to such an incident (Schulmeister 2018): “In a busy outpatient registration area, a recently hired clerk followed the facility’s procedure and entered the name printed on the patient’s driver’s license. She clicked the first name in the list that appeared on her computer screen and created a wristband, unaware that other patients with the same name existed in the system. The clerk asked the patient if the information on the band was correct, and he said yes. In court testimony later, he stated that he was not wearing his glasses at the time and was relying on the hospital staff to apply the correct wristband. The patient was sent to the busy infusion area at noon for his second chemotherapy treatment. A registered nurse asked him if his name was John Jones (name changed here for privacy) and if his birthday was the date that she read from his wristband. He nodded yes. But an error was made. The patient received the chemotherapy intended for another patient who had the same name but a different birthdate.” The problem of patient misidentification, of course, is not unique to cancer patients. But, given that chemotherapy agents are high-risk drugs, the consequences of such misidentifications in an oncology setting are likely to be particularly devastating.
Lastly a recent review of interventions to improve oral chemotherapy safety and quality shows we still have lots of room for improvement (Zerillo 2018). A literature search strategy identified almost 8000 abstracts in the peer-reviewed literature but only 16 full-text articles met inclusion criteria and the overall quality of the literature had shortcomings. Even those studies that had positive findings may not be generalizable because they were single institution studies or focused primarily on specific drugs or diseases. Many of the interventions and studies focused on adherence to chemotherapy. But among those that focused on safety/toxicity there was a trend toward lower toxicity profile in those interventions that focused on increased monitoring. Telephone calls, usually by an oncology nurse or pharmacist, shortly after initiation of a chemotherapy regimen were the most successful intervention. But the optimal frequency of calls and how long such calls should be continued are unknown. Drug diaries and pharmacist education on adverse effects were also noted to be useful interventions.
Our prior columns related to chemotherapy safety:
Some of our other columns on errors related to patient weights:
References:
Lipitz-Snyderman A, Pfister D, Classen D, et al. Preventable and mitigable adverse events in cancer care: Measuring risk and harm across the continuum. Cancer 2017; 123(23): 4728-4736
http://onlinelibrary.wiley.com/doi/10.1002/cncr.30916/abstract
Banasser G, Karpow C, Gaunt MJ, , Grissinger M. Medication Errors in Outpatient Hematology and Oncology Clinics. Pa Patient Saf Advis 2017; 14(4): 1-15
http://patientsafety.pa.gov/ADVISORIES/Pages/201712_oncology.aspx
Sato-DiLorenzo A, Wright D, Carvalho M, Coletti E, Zerillo J, Shea M. Combating chemotherapy verification fatigue: nurse-led quality improvement interventions in pre-treatment lab evaluation. Oral presentation at: ONS 43rd Annual Meeting; May 17-20, 2018; Washington, DC; presented May 18, 2018
https://ons.confex.com/ons/2018/meetingapp.cgi/Paper/2802
Schulmeister L. Cancer Treatment to the Wrong Patient: Why Does This Still Happen? Oncology Nursing News 2018; March 08, 2018
Zerillo JA, Goldenberg BA, Kotecha RR, et al. Interventions to Improve Oral Chemotherapy Safety and Quality. A Systematic Review. JAMA Oncol 2018; 4(1): 105-117
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June 19, 2018
More EHR-Related Problems
For being long-time advocates of healthcare IT as an important patient safety tool, it sure seems we write a lot about the unintended consequences of that same IT! See the numerous columns listed below for some of the issues we’ve discussed. Some more unintended consequences recently made the medical literature.
One involved a problem arising from use of an order set for acute MI (Gupta 2018). That order set included beginning a beta-blocker, which happened to be contraindicated in the actual patient for whom it was ordered. Its use led to worsening acute heart failure and cardiogenic shock in this patient.
The patient was a 58-year-old man who had a STEMI. He underwent PCI, during which an elevated left ventricular filling pressure was noted. Following the procedure, bradycardia, atrial fibrillation, and complete heart block on the ECG were noted. He was admitted to the coronary care unit and the admitting physician placed orders via the electronic medical record using the "STEMI admission order set". The patient developed worsening shortness of breath, bradycardia (lowest heart rate, 40/min), and hypotension (lowest blood pressure, 93/63 mm Hg), with crackles noted on auscultation of the lung fields consistent with developing cardiogenic shock.
Note that this order set had been developed 5 years earlier and had been reviewed and updated annually. House staff were encouraged to use this “opt in” order set for patients with STEMI. The order set included use of a beta-blocker because such use was originally a performance measure on admission and discharge (the hospital did not change the order set when it had later abandoned that performance measure). Also, though the admission note indicated the physician would withhold beta blockers because of heart failure and complete heart block, the "carvedilol" option on the order set was selected because it was the first and most visible option in the beta-blocker ordering window. The admitting physician also noted he was influenced by the clinical decision support (CDS) message stating that administering beta-blockers was a performance measure.
There were likely also communication errors between the interventional cardiology team and the inpatient cardiology team, resulting in the orders being given before the inpatient team knew all relevant information about the patient.
In the accompanying editorial (Shah 2018) Shah and Cifu note we are often slow to abandon outdated medical practices that are not based upon robust evidence.
Our May 3, 2016 Patient Safety Tip of the Week “Clinical Decision Support Malfunction” highlighted a study from Brigham and Women’s Hospital (BWH) in Boston about some disturbing findings on malfunctions of CDSS alerts (Wright 2016). Alarmingly, they found that the alert malfunctions were often very difficult to detect and some had eluded detection for long periods of time (weeks or even years!). Moreover, the causes for the malfunctions were sometimes even more difficult to elucidate. They were, however, able to identify several contributing factors:
These cases serve as a reminder that you must have a very active multidisciplinary team the oversees your clinical decision support systems (CDSS), even if you contract with an outside vendor for CDSS services. Each time you introduce a new clinical decision rule you need to review its use and impact within several weeks. You are looking primarily to see how often that rule is overridden or ignored and the reasons for that so you can determine whether or not to keep the rule. But once you’ve decided to keep the rule, you need to review it periodically. That should be at least annually and at any time there is a change in the evidence base. The vendors that most hospitals currently contract with for CDSS may issue updates every 6-12 months, but they often do not respond immediately when there is a change in the evidence base that might impact a specific rule. That is why you need to have your own active multidisciplinary team to act when there is a change in the evidence underlying the rule(s). The same applies to order sets. When there is a significant change or new finding in the evidence base, you need to review your standardized order sets that might be impacted by those changes. That means you need to have in place a detailed inventory of items from every order set. For example, let’s say the FDA comes out with a warning about a particular drug. You need to be able to readily identify any of your existing order sets that contain reference to that drug. So you need to have an easily “searchable” library of your order sets.
The Gupta case also highlights the problem that order sets often harbor items that are otherwise hard to detect. A good example of buried items comes from our discussions on inappropriate abbreviations (see our Patient Safety Tips of the Week for July 14, 2009 “Is Your 'Do Not Use' Abbreviations List Adequate?” and December 22, 2015 “The Alberta Abbreviation Safety Toolkit”). In that column we noted we had found pre-existing standardized order sets were a hidden source of many dangerous abbreviations.
In yet another study from Brigham and Women’s Hospital and Partners Healthcare, Wong and colleagues analyzed data on medication-related CDSS overrides in the ICU (Wong 2018). They found the overall appropriateness rate for overrides was 81.6% and varied by alert type. More potential and definite ADE’s (adverse drug events) were identified following inappropriate overrides compared with appropriate overrides (16.5 vs 2.74 per 100 over-ridden alerts). However, inappropriate overrides were over six times as likely to be associated with potential and definite ADE’s, compared with appropriate overrides (OR 6.14). They suggest that further efforts should be targeted efforts such as suppressing alerts that are appropriately over-ridden.
We have echoed the advice of many others that, in order to avoid alert fatigue, you limit the number of alerts your CDSS system triggers for clinicians and focus on those that are most important from a patient safety perspective.
We’ve also often emphasized that it’s important to rout alerts to the person most likely to intervene. That may not always be the physician. Often sending an alert to a pharmacist, who may then intervene with the ordering physician and suggest alternatives, may be the most appropriate routing of some clinical decision rules.
Howe and colleagues (Howe 2018) analyzed patient safety reports from the Pennsylvania Patient Safety Authority database from 2013 through 2016. They found 557 reports (0.03% of all reports) which had language suggesting the EHR potentially contributed to patient harm: potentially required monitoring to prevent harm (84%, n = 468), potentially caused temporary harm (14%, n = 80), potentially caused permanent harm (1%, n = 7), and could have required intervention to save a life or could have resulted in death (<1%, n = 2). They defined 7 categories of “usability factors”, with the following distribution of reports:
Regarding clinical processes, errors occurred during order placement (38%), medication administration (37%), review of results (16%), and documentation (9%).
One potential limitation of the study is that it only included reports which identified one of the top five EHR vendors/products.
Thoughtful design of order entry screens and standardized order sets is important in helping physicians make correct choices and avoid less optimal ones. A recent editorial by Vaughn and Linder (Vaughn 2018) discusses how “nudges” may be helpful. They note some designs provide a stimulus to do the wrong thing. For example, simply providing a checkbox may nudge a physician to check that checkbox. Providing the brandname of a drug may nudge the physician to order the more expensive formulation rather than a generic equivalent. And allowing a test to be ordered repetitively (eg. “daily CBC”) may lead to inappropriate testing.
They suggest the following questions be asked during design of order sets or order entry screens:
They stress the strong effect of using appropriate default settings. They cite a study that successfully reduced inappropriate urine cultures in an emergency room (Munigala 2018) by changing the default option from “urinalysis with reflex to urine culture” to “urinalysis with reflex to microscopy”. (See also our Patient Safety Tips of the Week for July 7, 2009 “Nudge: Small Changes, Big Impact” and February 18, 2018 “Nudged, But Who Nudged Who?” for examples of use of “nudges” in healthcare.)
And the issue of wrong patient events related to the EHR just won’t go away. We’ve discussed this in numerous columns. A 54-year old man died following routine knee surgery due to medications prescribed in the EHR that were intended for a different patient (Minion 2018). An anesthetist in Australia, while attending a new patient in the OR, opened the record of a previous patient to prescribe fluids necessary to “keep the line open” for intravenous antibiotics that had earlier been forgotten. But he forgot to close that patient’s electronic medical record. The anesthetist then prescribed doses of fentanyl meant for the patient currently in the OR but entered these by mistake in the open record of that previous patient. Apparently the HER did present multiple alerts while he was prescribing but all were overridden by the anesthetist, selecting ‘consultant’s decision’ and entering his password each time.
Interestingly, several of the key features of EHR’s that we have previously described (see our May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”) do not seem to have played a role in the error(s) in this case. The patient’s name was apparently displayed on all screens in this case. There was nothing to suggest juxtaposition errors or truncation errors. And it does not appear that two patient records were open at the same time or that 2 different applications were open at the same time. But the last feature we highlighted, failure to log off, was obviously the major problem here. We suspect that interventions such as those developed by Adelman and colleagues, including the ID-verify alert (prompt with name, age, gender and MD must verify) and ID-reentry function (MD must re-enter patient’s initials, age, gender) might have prevented the patient misidentification in the current case (see our August 1, 2017 Patient Safety Tip of the Week “Progress on Wrong Patient Orders”).
Lastly, it’s important to remember that EHR upgrades or conversions from one EHR to another represent times of vulnerability to errors. The Brigham and Women’s Hospital has had one of the most robust and most studied EHR’s from the standpoint of patient safety. Several of our columns (including references above in today’s column) have pointed out how it’s clinical decision support tools and alerts have been fine-tuned to reduce low-impact alerts and help avoid alert fatigue. But recently the system converted from their existing legacy EHR to a commercial EHR and some unintended consequences were found (Wright 2018). Though the knowledge base and content of drug-drug interaction (DDI) alerts was substantially the same between the two systems, the researchers found a striking drop off in the acceptance rates for DDI alerts after the conversion. Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts. After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7%. The researchers felt that the decrease in acceptance rates could not be fully explained by differences in the clinical knowledge base or by alert fatigue associated with increased alert burden. Instead, they felt that workflow factors played an important role. These included timing of alerts in the prescribing process, lack of differentiation of more and less severe alerts, and features of how users interact with alerts.
Information technology remains one of our most important patient safety tools. But there are important lessons learned in all these cases that can help us all avoid unintended consequences of our IT interventions.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Gupta A, Das SR, Pandey A. β-Blockers in Myocardial InfarctionIssues With Standard Admission Order Sets. JAMA 2018; 319(12): 1269-1270
Shah SD, Cifu AS. From Guideline to Order Set to Patient Harm. JAMA 2018; 319(12): 1207-1208
https://jamanetwork.com/journals/jama/article-abstract/2676090?redirect=true
Wright A, Hickman T-T T, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case series and survey. JAMIA 2016; First published online: 28 March 2016
http://jamia.oxfordjournals.org/content/early/2016/03/28/jamia.ocw005
Wong A, Amato MG, Seger DL, et al. Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit. BMJ Qual Saf Published Online First: 09 February 2018. doi: 10.1136/bmjqs-2017-007531
http://qualitysafety.bmj.com/content/early/2018/02/09/bmjqs-2017-007531
Howe JL, Adams KT, Hettinger AZ, Ratwani RM. Electronic Health Record Usability Issues and Potential Contribution to Patient Harm. JAMA 2018; 319(12): 1276-1278
https://jamanetwork.com/journals/jama/article-abstract/2676098?redirect=true
Vaughn VM, Linder JA Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf 2018; Published Online First: 24 March 2018
http://qualitysafety.bmj.com/content/early/2018/03/24/bmjqs-2017-007578
Munigala S, Jackups RR, Poirier RF, et al Impact of order set design on urine culturing practices at an academic medical centre emergency department. BMJ Qual Saf 2018; Published Online First: 20 January 2018
http://qualitysafety.bmj.com/content/early/2018/01/19/bmjqs-2017-006899
Minion L. Electronic prescribing error in month-old EHR responsible for death of NSW man, State Coroner finds. Healthcare IT News 2018; 06 April 2018
Wright, A, Aaron, S, Seger, D. et al. Reduced Effectiveness of Interruptive Drug-Drug Interaction Alerts after Conversion to a Commercial Electronic Health Record. J Gen Intern Med 2018; first online 15 May 2018
https://link.springer.com/article/10.1007%2Fs11606-018-4415-9#citeas
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June 26, 2018
Infection Related to Colonoscopy
Several years ago we were trying to help a hospital find benchmarks for colonoscopy complications. We were amazed that such benchmarks were not readily available. We discussed complications of colonoscopy in our November 15, 2011 Patient Safety Tip of the Week “Rethinking Colonoscopy” and noted that the few studies done did not separate out screening colonoscopies from diagnostic or therapeutic ones. Rates also depend on whether polypectomy was done, and also relate to the age of the population and associated comorbidities (Warren 2009). All these factors make it extremely difficult to compare rates of colonoscopy complications across facilities. Some of the same factors likely explain why rates at free standing ambulatory sites tend to be lower than at hospital-based endoscopy units.
Then, in our March 1, 2016 Patient Safety Tip of the Week “Colonoscopy Complications”, we noted a study from researchers at the Yale-New Haven Center for Outcomes Research and Evaluation (CORE) (Ranasinghe 2016) which found outpatient colonoscopies were followed by unplanned hospital visits within 7 days at an overall rate of 16.3/1000 colonoscopies, or a rate of about 1.6%. Hemorrhage, abdominal pain, and perforation were the most common causes of unplanned hospital visits.
In those columns, infections related to colonoscopies never were a significant part of our discussions. So we were quite taken aback at a recent study by researchers at Johns Hopkins (Wang 2018) that showed unexpectedly high rates of infection following colonoscopy (and also endoscopy) at ambulatory surgery centers (ASC’s).
The rates of postendoscopic infection per 1000 procedures within 7 days were 1.1 for screening colonoscopy, and 1.6 for non-screening colonoscopy (and 3.0 for esophagogastroduodenoscopies).
Predictors of postendoscopic infection included recent history of hospitalization or endoscopic procedure; concurrence with another endoscopic procedure; low procedure volume or non-freestanding ASC; younger or older age; black or Native American race and male sex. Rates of 7-day postendoscopic infections varied widely by ASC, ranging from 0 to 115 per 1000 procedures for screening colonoscopy, 0 to 132 for non-screening colonoscopy.
The most common organisms associated with infections were E. coli, Klebsiella, Clostridium difficile, and Staphylococcus species. And among those unplanned postprocedure visits, over 60% required hospitalization.
Infection as a complication of colonoscopy has caught most of us by surprise. Even the recently updated American Cancer Society guidelines (Wolf 2018) on screening for colorectal cancer don’t discuss infection. Those guidelines state “The principal recognized harms of CRC screening, which are rare, are those associated with colonoscopy (bleeding, perforation, cardiorespiratory complications of sedation) as a primary screening test or as a follow‐up of other positive noncolonoscopy tests.”
Perhaps many physicians performing colonoscopies have been unaware of their patients developing infectious complications because they had either unplanned emergency department visits or unplanned hospital admissions. The Hopkins researchers used an all-payer claims database with data from six states to track infection-related emergency room visits and unplanned inpatient admissions within seven and 30 days after a colonoscopy or EGD. Many ASC’s lack interoperability with hospital-based IT systems, so they often have no way of tracking such infectious complications.
The variation in infection rates across ASC’s was striking, with rates at some ASCs more than 100 times higher than expected.
So what does this mean for you? It obviously depends on whether you are a provider or a consumer. If you are an ASC performing endoscopies, you better find out what your rates of complications, including infections, really are (and stratify them by screening vs. nonscreening colonoscopy and whether polypectomy was performed). If you have no way of getting data from area hospitals regarding ED visits or hospitalizations of your patients after colonoscopy, you need to routinely contact your patients to find out whether complications occurred. Many ASC’s already make a phone call to patients 24-48 hours after a procedure, but the Hopkins study would suggest you need to also contact them later (perhaps at 30 days) to ensure you are identifying all complications.
And if you are a consumer, you’ll want to know the ASC’s rate for complications, infectious or otherwise, for colonoscopies (or EGD’s). If you can’t get that data, consider using a different ASC.
Colonoscopy is still a very valuable tool in the prevention and management of colorectal cancer. And guidelines for screening are expanding to begin screening earlier. The most recent American Cancer Society guidelines (Wolf 2018) recommend that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high‐sensitivity stool‐based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation.
The lack of accurate data on the complications of colonoscopy has made it difficult to assess the risk:benefit equations for colonoscopy as a screening tool for colorectal cancer. In fact, in our March 1, 2016 Patient Safety Tip of the Week “Colonoscopy Complications” we noted that the jump to colonoscopy as the most recommended tool was based upon the assumption that colonoscopy was more comprehensive than sigmoidoscopy (which had been shown to reduce colorectal cancer mortality) but that untoward consequences of colonoscopy had not really been factored into decisions.
It's incumbent upon all facilities performing colonoscopies to have accurate data on complications of these procedures. This obviously should apply not only to ASC’s but also to hospital-based colonoscopies. Many facilities may be surprised they are not doing quite as well as they thought they were.
References:
Warren J.L., Klabunde C.N., Mariotto A.B., et al: Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med 2009; 150: 849-857
http://www.annals.org/content/150/12/849.full
Ranasinghe I, Parzynski CS, Searfoss R, et al. Differences in Colonoscopy Quality Among Facilities: Development of a Post-Colonoscopy Risk-Standardized Rate of Unplanned Hospital Visits. Gastroenterology 2016; 150(1): 103-113
http://www.gastrojournal.org/article/S0016-5085%2815%2901353-0/abstract
Wang P, Xu T, Ngamruengphong S, Makary MA, et al. Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA. Gut 2018; Published Online First: 10 Apr 2018
http://gut.bmj.com/content/early/2018/05/18/gutjnl-2017-315308
Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average‐risk adults: 2018 guideline update from the American Cancer Society. CA: A Cancer Journal for Clinicians 2018; First published: 30 May 2018
https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21457
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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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